How to manage tuberosity fracture during extraction

Tuberosity fracture during extraction

Sudden, intra-operative fracture of maxillary tuberosity during upper molar extraction.

Presentation

Common site of occurrence

Upper third molars

Risk factors

• Dental anatomy characteristics or anomalies: long or bulbous roots, hypercementosis, multi-rooted teeth, lone standing upper molars, and highly pneumatized alveolus
• Pathoses: sinus disease, odontogenic cysts, periapical infection, ankylosis, osteoporosis and alveolar atrophy or, conversely, very dense bone
• Elevator use, particularly large elevators and elevators used as levers, rather than in a rotary fashion

Special considerations

• Special considerations should be given to systematically compromised patients: diabetics, immunosuppressed (AIDS, chemotherapy), previously radiated, renal disease sufferers, and those taking bisphosphonates for osteoporosis or metastatic malignant disease.

Signs

• Crunch or loud crack of bone breaking
• Sudden loosening of the tooth and bone together, with segment still attached to soft tissue
• Bone comes away with tooth during extraction
• Observable opening into the maxillary sinus: visible hole or "hollow" sound when suctioning the socket

Symptoms

• Patient may complain of sharp pain at the time of fracture or may be completely asymptomatic.
• If sinus perforation has occurred and diagnosis is delayed, the patient may complain of reflux of fluids from mouth to nose, sinus stuffiness, or present with overt sinusitis.

Investigation

Confirm clinical suspicion of fracture and assess displacement

• Gently, with minimal force and movement, assess the degree of mobility across the suspected fracture site. Determine the size of the fractured segment (in centimetres and number of teeth involved).
• Determine the size of the communication into the sinus.
• Document the situation with periapical or panoramic radiographs. The fracture may be difficult to detect on radiograph; however, baseline films to assess post-complication progress are important.

Diagnosis

• Confirmed mobility of fracture fragments
• Radiographic evidence of fracture
• Size of the fractured segment, dimensions in centimetres and number of teeth
• Size of the communication into the sinus, when detected

Treatment

The following should only be used as general guidance. In all situations, referral to an oral and maxillofacial surgeon (OMFS) should be considered, particularly if there are pathoses, systemic considerations, or a large fracture or sinus communication.

1. For a small fracture without sinus perforation: dissect the segment from gingiva and periosteum and suture.
   
   For a small fracture with sinus perforation (less than 3 to 4 mm): dissect the segment and close the socket primarily and consider using a Gelfoam^® sponge to obturate the opening.
2. If the area is infected, consider antibiotics and decongestants.
3. Include postoperative instructions to avoid nose blowing, smoking, etc., so the communication does not reopen.
4. For a large fracture: consider dissecting the tooth from the bony segment immediately (if possible) and stabilizing the segment by suturing primarily. This will likely require management of a concomitant oroantral communication. Management of a large (4 mm or greater) oroantral communication may require the mobilization of local flaps, autogenous or allogenic bone, or the use of synthetic materials. Such procedures are more specialized and referral to an OMFS is highly recommended. For very large segments that include multiple teeth: consider stabilization by wiring it to the adjacent teeth, allowing the segment to heal for 6 to 8 weeks and then returning for the extraction in a more controlled fashion. Referral to an OMFS for stabilization and eventual extraction is highly recommended.
5. Advise patient about possible oroantral fistula formation, sinusitis, and poorer retention for eventual prostheses.

THE AUTHOR

	Dr. Lapointe is professor and chair, division of oral and maxillofacial surgery, and assistant director of postgraduate studies, Schulich School of Medicine and Dentistry, London, Ontario. Email: Henry.Lapointe@schulich.uwo.ca or hlapoint@uwo.ca

The author has no declared financial interests.

This article has been peer reviewed.