Advances in Oral and Maxillofacial Surgery 1 (2021) 100018

Contents lists available at ScienceDirect

Advances in Oral and Maxillofacial Surgery

journal homepage: www.editorialmanager.com/adoms/default.aspx

A retrospective analysis of the impaction status of mandibular third molars

as a risk factor for fractures of angle or condylar region of the mandible
Aya Al-Harbawee a, *, Tauseef Ahmed a, Siddiq Ahmed b, Christopher Avery a, Rihab Fagiry a,
Hafizah Amer Hamzah a, Farooq Afzaal a, Aqib Khan a, Manish Mair a, Muhammad Ali a,
Faizan Farid a
a
University Hospital of Leicester, Leicester, United Kingdom
b
Bhitai Dental & Medical College, Mirpurkhas, Pakistan

A R T I C L E I N F O A B S T R A C T

Keywords: Background: The position and angulation of mandibular third molars (M3) have been found to influence the angle
Impacted lower third molar and condylar fractures. Due to variation in the results of relevant studies, this relationship remains not fully
Angle understood.
Condyle
Objective: To identify the association between the depth and angulation of M3 and the risk of fracture of the
Fracture
mandibular angle and condyle.
Methodology: A total of 527 patients were assessed from January 2012 to June 2020. Study variables included the
presence, position and angulation of M3. The outcome variables were angle and condylar fractures.
Results: Mean age was 28.5 years with 93.2% (n ¼ 499) were male. Angle fractures were significantly more
frequent with an impacted M3 (p ¼ 0.023) whereas condylar fractures were more commonly associated with a
fully erupted M3. The highest incidence of angle fractures was observed with M3 classified as class II (p ¼ 0.026)
and position B (p ¼ 0.05). In contrast, class I M3 were more frequently associated with condylar fractures. With
regards to the angulation, M3 between 80 – 100 were highly correlated with angle fractures (p ¼ 0.020)
whereas M3 angulations of 60 – 80 were related to condylar injuries (p ¼ 0.025).
Conclusions: Fractures of the mandibular angle were significantly associated with Class II and position B wisdom
teeth whereas class I were associated with fracture of the condyles. The likelihood of angle and condylar fractures
almost doubled when M3 angulations were (80ᵒ-100ᵒ) and (60ᵒ-80ᵒ) respectively.

1. Introduction association of M3 with mandibular fracture. At the same time, there is a

Despite the strength and the rigidity of the mandible, this bone is still
susceptible to fracture at several sites. The pattern of fractures varies
considerably amongst numerous studies. According to Rashid et al.
fractures of the angle and condyle accounted for 50% of all mandibular
injuries [1]. The aetiology of these fractures is multifactorial. One
important predisposing factors is impacted Mandibular third molar (M3).
There is overwhelming published literature supporting a relationship
between M3 with angle and condyle fractures [2–4]. When present, M3
could render the mandibular angle relatively weaker, increasing the
chance of a fracture [5]. In contrast, lower risk of condylar fractures has
been observed in patients with an impacted M3 [4].
There is a consensus among researchers acknowledging the
difference in opinion concerning the pattern of fracture. An association
between the angulation of M3 and angle fracture has been reported
Ma'aita et al. but other studies did not find a statistically significant
relationship [6,7]. The incidence of both fractures may vary with the
horizontal and vertical position of M3. A number of researchers have
reported that Pell and Gregory's (P&G) class IIB was mostly associated
with angle fractures [8–10] whilst others related class IIIC with this
pattern of fracture [11]. Due to the variation in the results, this area
would benefit from further research particularly if guidance is to be
established for the removal of impacted M3. The aim of this study was to
identify the association between the depth and angulation of M3
impaction and the risk of angle and condylar fractures. To the best of our
knowledge, this is one of the largest studies available with data collected
over the recent decade.

* Corresponding author.
E-mail address: aya.layth1994@gmail.com (A. Al-Harbawee).

https://doi.org/10.1016/j.adoms.2021.100018
Received 11 December 2020; Accepted 19 December 2020
Available online 11 January 2021
2667-1476/Crown Copyright © 2021 Published by Elsevier Ltd on behalf of British Association of Oral and Maxillofacial Surgeons. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A. Al-Harbawee et al. Advances in Oral and Maxillofacial Surgery 1 (2021) 100018

2. Material and methods

2.1. Study design

A retrospective cross-sectional analysis was performed for all eligible

patients presenting to the department of Oral and Maxillofacial surgery at
the University Hospital of Leicester (United Kingdom) between January
2012 and June 2020. We included subjects with isolated unilateral
fractures of the angle and condyle aged above 15 years old. Patients
presenting with bilateral angle and/or condyle (isolated or combined)
were excluded. Other exclusion criteria were (i)edentulisim, (ii)presence
of M3 with inadequate root formation, (iii)incomplete medical records or
(iv)diagnostically unacceptable radiographs.
Fig. 2. A) The angle between the long axis of M3 and the occlusal plan. B) The
2.2. Study variables vertical position of M3 in relation to the lower border of the mandible.

Panoramic radiographs were evaluated to assess the presence or

same distance from M2 root tip, it is classified as class α whereas in
absence of the M3 near the fracture site (primary predictor variable).
class β, the distance is less as compared to M2 [14].
These radiographs were analysed and traced using UVPACS software
(version 6.0,SP9.1.2 manufacture GE Healthcare,USA) to determine the
Other predictor variables included: age, gender and mechanism of
location of the fractures and the status of impaction. A set of positional
injury which was further subclassified into assault, fall, sports, road
data were assessed for all M3:
traffic accidents and other (seizure, occupational and unknown).
The primary outcome variable was the location of the fracture at
1. Horizontal and vertical positions were evaluated using P&G classifi-
either the angle or condyle, or occasionally both sites. In this study, we
cation [8]. The horizontal space between the mandibular ramus and
defined an angle fracture as located distal to M2 extending from any
M3 was classified into class I: sufficient eruptional space for M3; class
point of the curve formed by the lower border of the body and the pos-
II: insufficient space for full eruption; class III: M3 located within the
terior border of the ramus. Condyle fractures were identified when the
ramus. The vertical depth of M3 was categorised according to the
fracture line was at or above the level of the sigmoid notch [15].
level of M3 crown into position A: the level is at or above the occlusal
plan; position B: the level is between the occlusal plan and the
2.3. Data analysis
cementoenamel junction of the adjacent tooth; position C: the level is
below the cementoenamel junction (Fig. 1). Additionally, the
The statistical analysis was conducted using SPSS software, version
impaction status were ranked as superficial (class IA, class IB, class
21.0, (SPSS Inc., IBM, Armonk, NY, USA). Continuous data was tested for
IIB, class IIIA) and deep (class I, IIC, IIIB, IIIC).
distribution while non-normally distributed data was tested using the
2. The horizontal inclination between the longitudinal axis of the second
Mann-Whitney U test. In order to identify factors associated with the type
molar (M2) and M3 was categorised using Winter classification [12,
of fracture (i.e. angle or condyle), X2 and Fisher's exact tests were used to
13] into mesioangular, distoangular, vertical, horizontal and other
analyse categorical data. Binary logistic regression was used to complete
(Fig. 1). Additionally, the angle identified by the intersection between
multivariate analysis. P value of less than 0.05 was considered statisti-
the long axis of M3 and the occlusal plan was calculated (Fig. 2).
cally significant.
3. The vertical position of M3 in relation to the lower border of the
mandible was subdivided into class α and class β. When the shortest
distance from the lowest point of M3 roots is equal or greater than the

Fig. 1. Pell and Gregory classifications and Winter classifications of Mandibular third molars. Adapted from (33).

2
A. Al-Harbawee et al. Advances in Oral and Maxillofacial Surgery 1 (2021) 100018

3. Results Table 2
Distribution of third molar variables in the fracture groups.
3.1. Aetiological analysis of the fracture patterns and mandibular third Variable Study Angle Fracture Condylar P
molars (M3) Population Group Fracture Group Value
(n ¼ 395a) (n ¼ 305) (n ¼ 90)
A total of 527 patients were treated for angle and condyle fracture Winter Classification, n (%)
throughout the period from January 2012 to June 2020. Following the Vertical 182 (45.1) 135 (44.3) 47 (52.2) 0.183
exclusion of 45 cases that involved bilateral fractures, edentulisim and Horizontal 26 (6.6) 23 (7.5) 3 (3.3) 0.226
Mesioangular 154 (39) 123 (40.3) 31 (34.4) 0.315
M3 present as tooth germ, the eligible sample of 482 patients was divided Distoangular 33 (8.4) 24 (7.9) 9 (10) 0.521
into the angle (n ¼ 346) and condylar fracture (n ¼ 136) groups. The Angulation, n ¼ (%)
demographic results and the mechanism of injury are displayed in <0 2 (0.5) 1 (0.3) 1 (1.1) 0.404
Table 1. The mean patient age was 26.8 years in the angle fracture group 0–20 22 (5.6) 21 (6.9) 1 (1.1) 0.036
20–40 32 (8.1) 25 (8.2) 7 (7.8) 0.783
and 32.8 years in condylar group, with a significant age difference be-
40–60 51 (12.9) 40 (13.1) 11 (12.2) 0.679
tween the two fracture groups (p ¼ 0.008). Male patients were heavily 60–80 78 (19.7) 50 (16.4) 28 (31.1) 0.005
represented (93.2%; n ¼ 449) particularly within the angle fracture 80–100 164 (41.5) 133 (43.6) 31 (34.4) 0.047
group (OR 2.7; 95% CI 1.102–6.776; p ¼ 0.030). Females were more 100 46 (11.6) 35 (11.5) 11 (12.2) 0.846
likely to present with a condylar (11%) rather than angle fracture (5.2%). Pell and Gregory Vertical, n (%)
Position A 235 (59.5) 177 (58.0) 58 (64.4) 0.124
Assault was the most common cause of fracture in both the angle and Position B 126 (31.9) 105 (34.4) 21 (23.3) 0.05
condylar groups (69.1%, n ¼ 333), followed by falls (12.2%, n ¼ 58). The Position C 34 (8.6) 23 (7.5) 11 (12.2) 0.164
risk of angle fractures was almost doubled when physical aggression was Pell and Gregory Horizontal, n (%)
the cause of injury (p ¼ 0.032). Condylar fractures were 3 times more Class I 243 (61.5) 179 (58.7) 64 (71.1) 0.033
Class II 104 (26.3) 88 (28.9) 16 (17.8) 0.026
common than angle fractures with a fall (p ¼ 0.004). Only the minority of
Class III 48 (12.2) 38 (12.5) 10 (11.1) 0.731
cases were caused by traffic accidents or sports related. Depth of Impaction, n (%)
In 89% (n ¼ 310) of the 346 angle fractures and 66% (n ¼ 91) of 136 Superficial 342 (86.6) 266 (87.2) 76 (84.4) 0.498
condylar fractures M3 was present at the side of fracture. The presence of Deep 53 (13.4) 39 (12.8) 14 (15.6)
M3 was significantly associated with an increased incidence of angle Relationship of Third Molar to Inferior Border of Mandible, n (%)
Class α 306 (77.5) 235 (77) 71 (78.9) 0.714
fracture (OR 4.258; 95% CI 2.591–6.997; p ¼ <0.001). Angle fractures
Class β 89 (22.5) 70 (23) 19 (21.1)
were significantly more frequent with an impacted M3 (p ¼ 0.023)
a
whereas condylar fractures were more commonly seen with a fully 6 tooth germ-only patients excluded.
erupted M3. However, the latter association was not confirmed on
multivariate analysis (Table 3). No significant relationships were iden-
Table 3
tified between the number of roots and the pattern of mandibular frac-
Multivariate Analysis and Odds Ratio of significant variables.
ture (Table 1).
Variable Odds 95% Confidence P Value
Ratio Interval
Table 1
Patient demographics and third Molar status. Lower Upper

Variable Total Study Angle Condylar P Value Mandibular Angle Fracture Variables
Population Fracture Fracture Age 1.040 1.015 1.066 0.002
Group Group Gender 2.733 1.102 6.776 0.030
Mechanism of Injury (Assault) 1.786 1.050 3.038 0.032
Age, yr (Range ¼ n ¼ 482 n ¼ 346 n ¼ 136 Presence of Lower Third 4.258 2.591 6.997 <0.001
15–89) Molars***
Mean 28.52 26.83 32.83 <0.001 Condition of Third Molar: 1.331 0.606 2.922 0.477
Median 25 24 27 Impacted
Gender, n (%) n ¼ 482 n ¼ 346 n ¼ 136 Angulation (80–100 )
1.886 1.106 3.216 0.020
Male 449 (93.2) 328 (94.8) 121 (89) 0.023 Pell and Gregory Class B 1.124 0.531 2.378 0.760
Female 33 (6.8) 18 (5.2) 15 (11) Pell and Gregory Class II 1.247 0.583 2.666 0.570
Mechanism of n ¼ 482 n ¼ 346 n ¼ 136 Condylar Fracture Variables
Injury, n (%) Age 1.036 1.009 1.064 0.008
Assault 333 (69.1) 253 (73.1) 80 (58.8) 0.002 Gender 2.135 0.843 5.405 0.110
Fall 59 (12.2) 26 (7.5) 33 (24.3) <0.001 Mechanism of Injury (Fall) 3.082 1.427 6.655 0.004
Traffic Accident 11 (2.3) 7 (2) 4 (2.9) 0.514 Condition of Third Molar: Erupted 1.348 0.642 2.831 0.430
Sport 22 (4.6) 15 (4.3) 7 (5.1) 0.701 Angulation (60–80 ) 1.959 1.089 3.526 0.025
Other 57 (11.8) 45 (13) 12 (8.8) 0.201 Pell and Gregory Class I 1.060 0.480 2.340 0.885
Presence of lower n ¼ 482 n ¼ 346 n ¼ 136
third molars, n
(%)
3.2. Radiographic analysis of fracture patterns and impaction status of
Yes 401 (83.2) 310 (89.6) 91 (66.9) <0.001
No 81 (16.8) 36 (10.4) 45 (33.1) mandibular third molars (M3)
Number of roots, n n ¼ 401a n ¼ 310 n ¼ 91
(%) The M3 positional data were collected from the panoramic radio-
2 or more 320 (79.8) 248 (80) 72 (79.1) 0.903 graphs of 395 cases with fully developed M3. The most frequent hori-
Single 75 (18.7) 57 (18.4) 18 (19.8)
Tooth Germ Only 6 (1.5) 5 (1.6) 1 (1.1)
zontal and vertical positions were class I (n ¼ 243) and position A
Condition of lower n ¼ 395b n ¼ 305 n ¼ 90 (n ¼ 235) respectively. The highest incidence of angle fractures was
third molar, n observed in class II (p ¼ 0.026) and position B (p ¼ 0.05). In contrast class
(%) I molars were more frequently associated with condylar fractures
Incompletely 217 (54.9) 177 (58) 40 (44.4) 0.023
(Table 2). The depth of M3 impaction (superficial or deep) and the
erupted
Fully erupted 178 (45.1) 128 (42) 50 (55.6) relationship of M3 to the inferior border of the mandible did not correlate
a
with these fracture patterns. When Winter's classification was applied,
81 patients did not have presence of a lower third molar.
b there was a higher incidence of angle and condylar fractures with
6 tooth germ only patients excluded.

3
A. Al-Harbawee et al.
mesioangular and vertical impactions respectively, but this did not reach
statistical significance. With regard to the angulation of M3 with the
occlusal plane, Univariate analysis indicated angles between 0 – 20
were highly associated with angle fracture (p ¼ 0.026). Multivariate
analysis revealed a significant relationship between angulation and the
two fracture patterns. M3 angulation defined as 80 – 100 was highly
correlated with angle fracture (p ¼ 0.020) whereas angulation of 60 –
80 was associated with condylar injuries (p ¼ 0.025) (Table 3).
4. Discussion
The main objective of this study was to explore the associations be-
tween M3 impaction status and fracture of the mandibular angle and
condyle. This evidence is important to provide accurate prediction of the
location of potential fractures and the development of appropriate pre-
vention programmes for high risk groups. Several researchers have
argued that the presence of M3 predisposes to angle fractures but protects
against condylar fractures. Our retrospective analysis of 482 patients
confirmed that when an M3 was present, the risk of angle fracture was
increased by almost 4.5 times.
As far as the effect of an unerupted M3 is concerned, this study agrees
with the results from previous researches [7,16,17]. The prevalence of an
incompletely erupted M3 was significantly higher with angle fractures.
This observation can be explained by the fact that a partially erupted M3
disrupts the integrity of the cortical layer of the bone generating a
weakness point at the mandibular angle [2]. Moreover, a fully impacted
M3 occupying an osseous space within the angular bone increases sus-
ceptibility to fracture [18]. This hypothesis was supported by Reitzik
et al. who demonstrated the forces required to fracture a mandible con-
taining a partially erupted M3 were 60% lower than with a fully erupted
M3 [19].
In the current study, the number of condylar fractures was highest
with a fully erupted M3, which is in agreement with the findings indi-
cated by other reports [20–22]. It has been postulated that prophylactic
removal of M3 would strengthen the angle by increasing the
cross-sectional area and eliminating the fragile space [23,24]. Never-
theless, this would result in a mechanical stress concentration at weak-
ened aspects of the mandible, such as the condylar process, increasing the
likelihood of fracture [21,25]. In our study, this fact was observed with
fully erupted or missing M3 as a higher tendency for condylar fractures.
Bezerra et al. in a finite element analysis indicated the absence of an
M3 would allow higher energy transmission to the postero-lateral aspect
of the condylar neck [26]. Regarding surgical reduction and fixation,
condylar fractures were more laborious to treat appropriately in view of
the poor access and visibility [27]. Not only is accurate fixation a difficult
task but post-operative complications may be significant when compared
to intra-oral repair of angle fractures, for example; injury to the facial
nerve [28]. This article supports Zhu et al. and Armond et al. in keeping
M3 for fracture prevention [4,21].
In terms of the impaction status of M3, this research demonstrates a
significant correlation between the presence of impacted M3, especially
in Class II or position B, and an increased incidence of angle fracture.
These findings came in correspondence with the results published by
former articles [2,9,29]. It may be speculated that position B is located
deeper than position A, thereby creating a fragile area. However, when
position C was assessed there were no differences in the fracture risk.
This could be attributed to the low representation of position C molars in
our sample.
This study demonstrated the majority of class I patients suffered from
condylar injuries. This in turn could strengthen the hypothesis of the
dynamic energy transmission between the angle and condyle in presence
or absence of M3. A number of articles implied that only the horizontal
position of M3 influences the pattern of fracture regardless of the occlusal
level [14,30]. In contrast, Ma'aita et al. correlated a vertical position,
specifically position A, with an increased risk of angle fracture [7]. Given
4
Advances in Oral and Maxillofacial Surgery 1 (2021) 100018
these discrepancies between published reports, it seems that P&G clas-
sification does not clearly reflect the biomechanics of the mandibular
bone when subjected to various impact forces. Ultimately, this may un-
lock new opportunities for clinical research.
To overcome these limitations, we analysed the position of M3 in
relation to the inferior border of the mandible. We anticipated a higher
incidence of angular fracture and a lower risk of condylar fracture when
the M3 were located near the mandibular border. Nevertheless, no sig-
nificant differences were recognised between class α and β. Corre-
sponding with previous studies, we could not identify significant
associations when classified using the Winter's classification [2,4].
However, in this article, we calculated an additional angle between the
long axis of M3 and the occlusal plan and identified a significant increase
in the fracture risk in relation to different angulation of M3. Outcomes
from multivariant analysis highlighted the odds of angle and condylar
fractures almost doubled when M3 angulations were (80o-100 ) and
(60o-80 ) respectively. This finding challenges the theory, suggested by
previous studies that the root slope provided in mesial angulation can
precipitate a fracture at the angle [2]. Nevertheless, these results should
be interpreted with caution as angulations were calculated using a
two-dimensional radiograph of a three-dimensional object. In view of
this limitation, we recommend further research to evaluate these findings
by engaging 3D measurements of M3 angulations.
In conclusion, this study confirms that impacted M3 predispose to
fracture of the mandible whilst offering relative protection against
condylar fractures. The highest incidence of angle fracture was with class
II position A compared to class I position with condylar fractures. The
likelihood of angle and condylar fractures were almost doubled when M3
angulations were (80o-100 ) and (60o-80 ) respectively. There were no
statistical associations in the risk of fracture patterns with Winter clas-
sification, or the distance between the lower border of the mandible and
depth of M3 impaction.
Conflicts of interest
None declared.
Ethics statement/confirmation of patient permission
Ethics approval yes. Patient permission not applicable.
Funding
This research did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors.
Authors of this manuscript declare the work described has not been
published previously and it is not under consideration for publication
elsewhere. The publication of this manuscript is approved by all authors
and tacitly or explicitly by the responsible authorities where the work
was carried out, and that, if accepted, it will not be published elsewhere
in the same form, in English or in any other language, including elec-
tronically without the written consent of the copyright holder.
CRediT authorship contribution statement
Aya Al-Harbawee: Conceptualization, Data curation, Investigation,
Methodology, Project administration, Validation, Visualization, Writing -
original draft. Tauseef Ahmed: Data curation, Formal analysis, Investi-
gation, Methodology, Software, Visualization, Writing - original draft.
Siddiq Ahmed: Writing - original draft, Supervision. Christopher
Avery: Supervision, Writing - review & editing. Rihab Fagiry: Investi-
gation. Hafizah Amer Hamzah: Investigation. Farooq Afzaal: Investi-
gation. Aqib Khan: Investigation. Manish Mair: Supervision.
Muhammad Ali: Supervision, Writing - review & editing. Faizan Farid:
proofreading.
A. Al-Harbawee et al. Advances in Oral and Maxillofacial Surgery 1 (2021) 100018

References [15] Kelly DE, Harrigan WF. A survey of facial fractures: bellevue Hospital, 1948-1974.
J Oral Surg Am Dent Assoc 1965 1975 Feb;33(2):146–9.
[16] Thangavelu A, Yoganandha R, Vaidhyanathan A. Impact of impacted mandibular
[1] Rashid A, Eyeson J, Haider D, van Gijn D, Fan K. Incidence and patterns of
third molars in mandibular angle and condylar fractures. Int J Oral Maxillofac Surg
mandibular fractures during a 5-year period in a London teaching hospital. Br J Oral
2010 Feb;39(2):136–9. 1.
Maxillofac Surg 2013 Dec;51(8):794–8.
[17] Choi B-J, Park S, Lee D-W, Ohe J-Y, Kwon Y-D. Effect of lower third molars on the
[2] Armond ACV, Martins CC, Gl
oria JCR, Galv~ao EL, dos Santos CRR, Falci SGM.
incidence of mandibular angle and condylar fractures. J Craniofac Surg 2011 Jul;
Influence of third molars in mandibular fractures. Part 1: mandibular angle—a
22(4):1521–5.
meta-analysis. Int J Oral Maxillofac Surg 2017 Jun;46(6):716–29. 1.
[18] Safdar N, Meechan JG. Relationship between fractures of the mandibular angle and
[3] Giovacchini F, Paradiso D, Bensi C, Belli S, Lomurno G, Tullio A. Association
the presence and state of eruption of the lower third molar. Oral Surg Oral Med Oral
between third molar and mandibular angle fracture: a systematic review and meta-
Pathol Oral Radiol Endod 1995 Jun;79(6):680–4. 1.
analysis. J Cranio-Maxillo-fac Surg Off Publ Eur Assoc Cranio-Maxillo-fac Surg.
[19] Reitzik M, Lownie JF, Cleaton-Jones P, Austin J. Experimental fractures of monkey
2018 Apr;46(4):558–65.
mandibles. Int J Oral Surg 1978 Apr;7(2):100–3. 1.
[4] Armond ACV, Martins CC, Gl
oria JCR, Galv~ao EL, dos Santos CRR, Falci SGM.
[20] Iida S, Nomura K, Okura M, Kogo M. Influence of the incompletely erupted lower
Influence of third molars in mandibular fractures. Part 2: mandibular condyle—a
third molar on mandibular angle and condylar fractures. J Trauma 2004 Sep;57(3):
meta-analysis. Int J Oral Maxillofac Surg 2017 Jun;46(6):730–9. 1.
613–7.
[5] Rogers HW, Weinstock MA, Feldman SR, Coldiron BM. Incidence estimate of
[21] Zhu S-J, Choi B-H, Kim H-J, Park W-S, Huh J-Y, Jung J-H, et al. Relationship
nonmelanoma skin cancer (keratinocyte carcinomas) in the U.S. Population, 2012.
between the presence of unerupted mandibular third molars and fractures of the
JAMA Dermatol 2015 Oct;151(10):1081–6.
mandibular condyle. Int J Oral Maxillofac Surg 2005 Jun;34(4):382–5.
[6] Ma’aita J, Alwrikat A. Is the mandibular third molar a risk factor for mandibular
[22] Patil PM. Unerupted lower third molars and their influence on fractures of the
angle fracture? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000 Feb;89(2):
mandibular angle and condyle. Br J Oral Maxillofac Surg 2012 Jul;50(5):443–6.
143–6.
[23] Schwimmer A, Stern R, Kritchman D. Impacted third molars: a contributing factor
[7] Gaddipati R, Ramisetty S, Vura N, Kanduri RR, Gunda VK. Impacted mandibular
in mandibular fractures in contact sports. Am J Sports Med 1983 Aug;11(4):262–6.
third molars and their influence on mandibular angle and condyle fractures – a
[24] Yamada T, Sawaki Y, Tohnai I, Takeuchi M, Ueda M. A study of sports-related
retrospective study. J Cranio-Maxillo-Fac Surg 2014 Oct;42(7):1102–5. 1.
mandibular angle fracture: relation to the position of the third molars. Scand J Med
[8] Pell G, Gregory G. Impacted mandibular third molars : classification and modified
Sci Sports 1998 Apr;8(2):116–9.
techniques for removal. Dent Digest 1933;39(330).
[25] Lee JT, Dodson TB. The effect of mandibular third molar presence and position on
[9] Rahimi-Nedjat RK, Sagheb K, Jacobs C, Walter C. Association between eruption
the risk of an angle fracture. J Oral Maxillofac Surg 2000 Apr;58(4):394–8. 1.
state of the third molar and the occurrence of mandibular angle fractures. Dent
[26] Bezerra TP, Silva FI, Scarparo HC, Costa FWG, Studart-Soares EC. Do erupted third
Traumatol 2016;32(5):347–52.

Di Nardo MD, Szalma J. Association between third molars weaken the mandibular angle after trauma to the chin region? A 3D finite
[10] So
os B, Janovics K, T

oth A,
element study. Int J Oral Maxillofac Surg 2013 Apr;42(4):474–80. 1.
molar impaction status and angle or condylar fractures of the mandible: a
[27] Ea A-MEE. Surgical treatment of adult mandibular condylar fractures provides
retrospective analysis. J Oral Maxillofac Surg Off J Am Assoc Oral Maxillofac Surg
better outcomes than closed treatment: a systematic review and meta-analysis
2020 Jul;78(7):1162.e1–8.
[Internet]. J Oral Maxillofac Surg: Official J Am Assoc Oral Maxillofacial Surgeons.
[11] Ruela W de S, de Almeida VL, Lima-Rivera LM, Santos PL, Porporatti AL, de
J Oral Maxillofac Surg 2015;73 [cited 2020 Sep 16]. Available from, https://pubm
Freitas PHL, et al. Does an association exist between the presence of lower third
ed.ncbi.nlm.nih.gov/25577459/.
molar and mandibular angle fractures?: a meta-analysis. J Oral Maxillofac Surg Off
[28] Brown AE, Obeid G. A simplified method for the internal fixation of fractures of the
J Am Assoc Oral Maxillofac Surg 2018;76(1):34–45.
mandibular condyle. Br J Oral Maxillofac Surg 1984 Apr;22(2):145–50. 1.
[12] Shiller WR. Positional changes in mesio-angular impacted mandibular third molars
[29] Duan DH, Zhang Y. Does the presence of mandibular third molars increase the risk
during a year. J Am Dent Assoc 1979 Sep;99(3):460–4. 1939.
of angle fracture and simultaneously decrease the risk of condylar fracture? Int J
[13] Winter GB. Principles of exodontia as applied to the impacted mandibular third
Oral Maxillofac Surg 2008 Jan;37(1):25–8. 1.
molar: a complete treatise on the operative technic with clinical diagnoses and
[30] Samieirad S, Eshghpour M, Dashti R, Tohidi E, Javan AR, Mianbandi V. Correlation
radiographic interpretations. St. Louis, Mo: American medical book company; 1926.
between lower third molar impaction types and mandibular angle and condylar
p. 127–31.
fractures: a retrospective study. J Oral Maxillofac Surg 2019 Mar;77(3):556–64. 1.
[14] Iida S, Hassfeld S, Reuther T, Nomura K, Mühling J. Relationship between the risk
of mandibular angle fractures and the status of incompletely erupted mandibular
third molars. J Cranio-Maxillo-Fac Surg 2005 Jun;33(3):158–63. 1.