Let’s be honest, a few sounds in the dental office can strike more terror into a dentist’s heart than into the patient’s. There’s the dreaded sound of a bur breaking an endodontic file, the snap of an instrument tip, and perhaps the most startling of all: that distinct “CRACK” you hear while extracting a stubborn upper wisdom tooth.
In that very moment, your heart pounds. You frantically ask yourself, “Was that a root fracture, or…?” As you complete the extraction, the catastrophe unfolds: the tooth comes out, bringing with it a sizeable piece of bone. Congratulations, you’ve just fractured the Maxillary Tuberosity.
This situation, clinically termed a Maxillary Tuberosity Fracture, is one of the more common complications associated with maxillary third molar extractions. In such a critical moment, maintaining composure and thinking clearly are what truly distinguish professional management from exacerbating the problem for the patient.
The most pressing question that immediately comes to mind is: “Should I reposition this fractured bone fragment, or simply remove and discard it?”
In this article, we’ll provide you with a clear, straightforward protocol to help you make the correct decision in this challenging scenario.
Why Does the Tuberosity Fracture Anyway? (Understanding the Risk Factors)
To effectively prevent this complication, you first need to understand why it occurs. There are several indicators that, if observed on a radiograph or during a clinical examination, should immediately raise a red flag:
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Lone Standing Molar: When a third molar is the most posterior tooth in the arch with no adjacent tooth mesially, the surrounding bone tends to be weaker and more susceptible to fracture.
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Large Maxillary Sinus: If the maxillary sinus extends very close to the tooth roots, the bone separating them can be exceptionally thin.
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Fused or Divergent Roots: Abnormally shaped or fused roots significantly complicate the extraction process, exerting increased stress on the surrounding bone.
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Ankylosis: When the tooth root is fused directly to the bone, extraction becomes exceptionally difficult.
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Over-aggressive Force: Attempting to extract the tooth with excessive, uncontrolled force instead of employing proper surgical technique.
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Patient Age: Older patients typically have less elastic and more brittle bone, making them more prone to fractures.
Disaster Struck. Now What? (The Immediate Management Protocol)
You heard the crack, and you’ve confirmed the tuberosity fracture. First step: absolutely do not panic! Take a deep breath, and reassure your patient, who has likely sensed something unusual. Second step, you must meticulously assess the situation.
Ask yourself two critical questions:
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What’s the size of the fracture? Is it a small fragment or a substantial piece of bone?
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Is this bone fragment still attached to the overlying gingival tissue, or has it completely separated?
The answer to that second question will entirely dictate your subsequent decision-making.
Decision Protocol: Replace or Remove? (To Replace or To Remove?)
You essentially have two, and only two, scenarios:
Scenario One: The Fragment is Still Attached
If you find that the fractured bone segment remains connected to the overlying Mucoperiosteum, you are in a relatively safer position.
Why? Because this mucoperiosteum acts as the “lifeline” for the bone, supplying it with blood and nutrients. As long as this vital connection exists, the bone fragment is still viable and has the potential to heal if repositioned.
What to Do:
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Do NOT proceed with conventional extraction! If you attempt to pull the tooth, you will undoubtedly sever the mucoperiosteal attachment, transforming it into a completely detached fragment.
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The smarter solution is to surgically separate the tooth from the bone. Take a surgical blade and carefully dissect between the tooth roots and the fractured bone segment. Remove the tooth alone, leaving the bone fragment in its original position, connected to the gingiva.
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Gently reposition the bone fragment back into its correct anatomical location and apply light pressure.
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Suture the wound meticulously to stabilize the fragment in place. Consider using a Figure-of-eight or Horizontal mattress suture for optimal stability.
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An Alternative Option: If you feel the situation is too complex, or the tooth remains excessively resistant to extraction, you might make a very courageous decision: postpone the extraction. Reposition everything, suture well, prescribe antibiotics and analgesics, and advise the patient to return in 6-8 weeks. During this period, the bone will begin to heal, making the subsequent extraction of the tooth alone significantly easier (1).
Scenario Two: The Fragment is Completely Detached
This is when the tooth emerges, and the bone fragment is in your hand, completely separated from the gingival tissue.
Why Can’t We Replace It? Because this bone fragment is now devitalized. It has lost its blood supply. If you attempt to replace it, the body will treat it as a “foreign body,” leading to significant inflammation, infection, and other severe complications.
What to Do:
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Completely remove the bone fragment.
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Carefully inspect the wound. If there are any sharp bony edges, you must smooth them using a bone file or a surgical bur.
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The Most Critical Step: You must treat this wound as if there is an Oroantral Communication (OAC), even if you don’t visualize an obvious opening.
The Elephant in the Room: Managing Oroantral Communication
This is arguably the most crucial point in the entire scenario. The Maxillary Tuberosity constitutes a portion of the posterior wall of the maxillary sinus. When it fractures, the likelihood of the sinus wall itself being perforated becomes exceptionally high.
The Golden Rule: In any case of maxillary tuberosity fracture, always assume the presence of an OAC until proven otherwise.
How to Close This OAC?
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You must achieve primary closure of the wound. This means completely sealing the gingival tissue over the opening without any tension.
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You will most likely need to create a buccal advancement flap. Make a small incision in the periosteum of the flap to allow it to stretch sufficiently and securely cover the defect.
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Suture the wound meticulously with tight, close sutures to ensure a complete seal.
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Provide the patient with specific post-operative instructions for OAC management:
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No nose blowing or sniffing for two weeks.
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If sneezing, do so with an open mouth to prevent pressure buildup.
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Strictly no drinking with a straw or blowing balloons.
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Absolutely no smoking.
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Prescribe an appropriate regimen: a suitable antibiotic (such as Augmentin), a decongestant (like Otrivin drops), and an analgesic (2, 3).
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The Takeaway: The “Juice” in Two Minutes
When the tuberosity fractures during an extraction, stay calm. Follow these steps:
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Assess the situation: Is the bone fragment attached to the gingiva or not?
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If Attached: Surgically separate the tooth, leave the bone, reposition it, and suture meticulously. Alternatively, consider postponing the extraction.
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If Detached: Remove the fragment, smooth any sharp bone, and manage the wound as an OAC.
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In Either Scenario: Always assume an OAC, ensure impeccable primary closure of the wound, and provide correct post-operative instructions and prescriptions.
And perhaps most importantly, prevention. Always meticulously review radiographs before beginning, and if you sense a high-risk situation, be prepared with a “Plan B” at all times.
