Exodontia.Info
Fractured Maxillary Tuberosity
The maxillary tuberosity is the most hind-most (distal) aspect of the upper jaw (maxilla), housing the
sockets of the upper wisdom teeth, with its back (
posterior) border curving upward and distally.

The upper wisdom tooth lies just in front and within the maxillary tuberosity.
Pictures showing the location of the Maxillary Tuberosity
When an upper premolar / bicuspid (rare) or an upper molar (more likely) is extracted, there is a risk that the bony socket
comes out with the tooth.  This is mainly the roof of the mouth side).  This is often accompanied by tearing of the gum (both
cheek and roof of the mouth side, but mainly the roof of the mouth side).

The fracture of a large portion of bone in the
maxillary tuberosity area is a situation of special concern.  The maxillary
tuberosity
is especially important for the stability / retention of upper dentures and may cause a mouth-sinus comminication
(
oro-antral communication).

If there is a large
maxillary tuberosity fracture, the aim is to salvage the fractured bone in place and to provide the best
possible environment for healing.

Routine treatment of the large
maxillary tuberosity fractures is to stabilise the mobile part(s) of bone with rigid fixation
techniques (i.e. splinting with archbars or immobilisation with a plastic splint) for 4 - 6 weeks.

Following adequate healing, a surgical extraction procedure may be attempted. However, if the tooth is infected /
symptomatic at the time of the
tuberosity fracture, the extraction should be continued by loosening the cuff of gum and
removing as little bone as possible while attempting to avoid separation of the
tuberosity from the layer of skin immediately
overlying the bone (
periosteum).

If the attempt to remove the attached bone is unsuccessful and the infected tooth is delivered with the attached
tuberosity, the
tissues should be closed with watertight stitches (
sutures) as there may not be a clinical oro-antral communication.

The Oral Surgeon may elect to graft the area after 4 - 6 weeks of healing and post-
operative antibiotic therapy.  If the tooth is
symptomatic but there is no frank sign of purulence or infection, the Oral Surgeon may elect to attempt to use the attached
bone as an
autogenous graft.

The factors predisposing to a fractured
maxillary tuberosity during extraction of upper molars are:

Tooth-Related Factors:

  • Bulbous roots
  • Dilacerated / divergent roots
  • Fused roots
  • Multi-rooted
  • Lone-standing / last standing molars
  • Deeply Impacted Maxillary 3rd Molars
  • Hypercementosis
  • Ankylosis


Surrounding Anatomy:

  • Large sinus, expanding to extent of tuberosity
  • Roots into sinus
  • Resorbed maxilla (especially following premature loss of the 1st molar)
  • Sclerotic tuberosity


Pathological Factors:

  • Large peri-apical infection
  • Cystic change


Procedure-Related Factors:

  • Unsupported extraction technique
  • Removal of multiple maxillary teeth leaving the most distal one to the last
  • Excessive force is used to remove the tooth


Not only forceps extraction of a resistant second or third molar but also first molar may result in fracture of the
maxillary
tuberosity
.

All Oral Surgeons who practice
exodontia must be able to manage this complication, immediately the problem occurs.

"Mild / Small Tuberosity Fracture"
Extracted Upper Molar with Adherent Tuberosity, Pterygoid Plates, Blood Supply & Muscles
"Severe / Catastrophic Tuberosity Fracture"
Useful Articles:


British Dental Journal 2005.  An extraction complicated by lateral and medial pterygoid tethering of a fractured maxillary
tuberosity.

Eur Dent J 2007.  Maxillary Tuberosity Fracture associated with 1st Molar Extraction - A Case Report

BJOMS 2009.  Interesting Case. Dento-Alveolar Fracture of the Posterior Maxilla

Austral Dent J 2011.  Maxillary Tuberosity Fracture - A Life-Threatening Hæmorrhage following Simple Exodontia

BDJ 2011.  Oro-Antral Fistulae & Fractured Tuberosities

Dental Traumatology 2011.  Considerations of Maxillary Tuberosity Fractures during Extraction of Upper Molars - A Literature
Review

J Nat Sci Biol Med 2013.  Tuberosity Fracture & Subconjunctival Hemorrhage following Extraction of Maxillary 3rd Molar

J Can Dent Assoc 2014.  How to Manage Tuberosity Fracture during Extraction

Swiss Dent J 2014.  The Most Common Complications After Wisdom-Tooth Removal.  Part 2.  A Retrospective Study of
1,562 Cases in the Maxilla

J Education Health & Sport 2017.  Iatrogenic Fracture of the Maxillary Tuberosity – A Case Report

Oral Surgery 2017.  Maxillary Tuberosity Fracture & Ophthalmologic Complications following Removal of Maxillary 3rd Molar

Clin Case Rep 2018.  Dento-Alveolar Fracture - A Complication of Extraction of Upper Left 1st Molar

The Dental Defence Union 2018.  Fractured tuberosity during extraction
Last Updated 13th February 2020
Extracted Upper Molars with Larger Piece of Adherent Tuberosity
"Moderate / Medium Tuberosity Fracture"
Classification of Fractured Tuberosities