Unexpected hemorrhage during upper third molar extraction

Maxillary tuberosity fractures can lead to unexpected hemorrhage during maxillary third molar extraction. Preoperative radiological examinations investigating root morphology can help prevent tuberosity fractures. Contrast-enhanced computed tomography (CT) enables the determination of the accurate anatomical position of the posterior superior alveolar artery. Herein, we report a case of tuberosity fracture and unexpected hemorrhage during maxillary third molar extraction, retrospectively reviewing CT findings. A 37-year-old man was referred to our department with persistent hemorrhage after the extraction of the left upper third molar, which was revealed to have four roots on preoperative CT. Intraoral examination revealed active hemorrhage from the extraction site. Contrast-enhanced CT performed in our hospital showed fractures of the left maxillary tuberosity and the posterior superior alveolar artery leading to the fracture site. Sutures were applied with packing gauze and hemostatic microfibrous collagen, and complete hemostasis was achieved over several days. Preoperative CT can provide useful information regarding root morphology; in case of unexpected hemorrhage, CT angiography can provide valuable information regarding the responsible vessel. Close preoperative examination of the dental morphology using CT may help choose and perform appropriate surgical techniques, while CT angiography may be useful in evaluating the surrounding anatomical structure that may be utilized for hemorrhage arrest.