Pathological fractures of the mandible: A report of ten cases and a review of the literature

doi:10.4236/ojst.2013.38070

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Open Journal of Stomatology, 2013, 3, 419-424 OJST

http://dx.doi.org/10.4236/ojst.2013.38070 Published Online November 2013 (http://www.scirp.org/journal/ojst/)

Pathological fractures of the mandible: A report of ten

cases and a review of the literature*

Badreddine Abir#, Alae Guerrouani, Abdeljalil Abouchadi

Department of Plastic, Maxillo-Facial Surgery and Stomatology, Mohamed V Military Hospital, Rabat, Morocco

Email: #[email protected]

Received 30 October 2012; revised 15 October 2013; accepted 26 October 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Introduction: Pathological fractures of the mandible

are rare. They account for approximately 2% of all

mandibular fractures. The main purpose of the study

is to report our experience concerning this condition

and to analyse data and review the literature avail-

able. Material and methods: This study reviewed

retrospectively the records of patients who presented

to the department of Plastic and Maxillofacial sur-

gery between 2000 and 2008 with a pathological

fracture of the mandible. The collected data included

age, sex, mechanism of injury, aetiology, anatomic

site of fracture, treatment and complications. Results:

There were 10 patients with an average age of 48

years and 10 months. There were three cases of frac-

ture due to a local malignancy, two cases of osteora-

dionecrosis, two cases of mandibular cysts, one pa-

tient presenting a mandibular histiocytosis, one pa-

tient with a metastatic carcinoma (Thyroid), and one

case related to mandibular atrophy. Most common

mechanisms of injury were chewing and falls. Patho-

logical fractures were often located in the body of the

mandible. A surgical approach was performed in

most cases. Conclusion: Surgical management of pa-

thological fractures of the mandible depends largely

on the aetiology. Complications occur more often be-

cause of local condition and bad oral hygiene.

Keywords: Mandibular Fracture; Pathological Fracture

1. INTRODUCTION

Mandibular fractures are common after high energy fa-

cial injury; they represent 36% to 59% of all facial frac-

tures [1]. However, pathological fractures of the mandi-

ble are uncommon and represent less than 2% of all

mandibular fractures [2]. This kind of fracture occurs

from a very low energy injury or normally tolerated

loading forces in a bone weakened by a pathological

condition. Actually, this definition remains controversial,

because: a) A low-energy injury is difficult to define and

to quantify by scientific means; and b) This definition

can’t cover all pathological mandibular fractures [3].

Others suggest that pathological fractures occur through

a pre-existing lesion or in a diseased part of the bone [4].

This study was realized to determine the aetiology of

bony condition that leads to pathological fractures of the

mandible seen in our experience, their sites and the

treatments we proposed.

2. MATERIAL AND METHODS

Between September 2000 and July 2008, 10 patients

were treated for pathological fracture of the mandible in

our department. Patients’ data including: sex, age,

mechanism of injury, aetiology, fracture site, treatment

and the presence of postoperative complication were

analysed and compared with previously published data.

3. RESULTS (TABLE 1)

During this period, 317 patients with fractures of the

mandible were treated in the department of Plastic and

Maxillofacial Surgery. Ten patients were presenting a

pathological fracture of the mandible which represents

3,1% of all mandible fractures seen during the same pe-

riod. Th e sex ratio was 6 mal e/4 f emale. The a verag e age

of the patients was 48.8 with a range of 24 - 76 years.

The main mechanism of the injury was minimal trauma

during mastication (04 cases). Two patients suffered an

injury during a fall, two fractures were iatrogenic fol-

lowing dental extraction procedures, and in two cases

patients suffered mandible fracture because of a road

accident. Regarding aetiology, three patients were diag-

nosed with direct invasion o the mandible by a primary

*Conflict of interest: none

#Corresponding author. f

OPEN ACCESS

B. Abir et al. / Open Journal of Stomatology 3 (2013) 419-424

420

Table 1. Demographic , c l i nical data, aetiology and treatment referring to the group of examined patients.

Cas Sexe Age (yrs) injury Aetiology Location Treatment

1 M 24 Surgical remove

of teeth 36 Osteoradionecrosis Mandibular body Free flap

2 M 38 Fall Metastatic thyroid carcinoma Mandibular body Conservative treatment

3 M 44 Chewing Oral squamous cell carcinoma Symphysis Free flap

4 F 42 Chewing Osteoradionecrosis Angle Free flap

5 F 57 Road accident Periapical cyst Mandibular body Enucleation + Maxillomandibular

fixation

6 M 52 Fall Mandibular histiocytosis Mandibular body Bone graft

7 F 65 Chewing Oral squamous cell carcinoma Symphysis Reconstruction plate

8 M 76 Road accident Mandibular atrophy Mandibular body Reconstruction plate

9 M 45 Chewing Oral squamous cell carcinoma Mandibular body Free flap

10 F 45 Surgical remove

of teeth 48 Mandible cyst Angle Enucleation + maxillomandibular

fixation

malignant tumour (Figure 1), two patients were diag-

nosed with osteoradionecrosis (ORN) of the mandible

(Figures 2-4), two patients had mandible cysts (Figure

5), only one patient was presenting a mandibular atrophy

(Figure 6), one patient presented a metastatic thyroid

carcinoma and one patient was presenting a mandibular

histiocytosis. In 8 patients fractures concerned the man-

dibular body, in the two other cases they occurred in the

angle.

Most of the patients were qualified for surgical treat-

ment: Segmental mandibulectomy was realized in 05

patients (02 patients with ORN and 03 patients with local

malignancy) and cyst enucleation was performed in two

cases. Reconstruction was performed using titanium re-

construction plates in 02 patients (Figure 6), iliac crest

bone graft was needed in 01 patient (Figure 7), and free

fibula flap was used in 04 patients (Figures 8 and 9).

Maxillomandibular fixation was applied for 6 weeks in

02 patients (associated to cyst enucleation). In one pa-

tient, the general health status did not permit aggressive

procedure and conservative treatment was indicated (liq-

uid diet and antibiotics). Patients with o steoradionecrosis

ORN were all sent to hyperb aric ox ygen un it for 30 to 40

pre-surgical and post-surgical daily treatment sequences.

Complication rate was 40%: we have seen exposed

plates in 02 patients, surgical site infection in one pa-

tient and a late failure of the free fibula flap in one pa-

tient.

4. DISCUSSION

Pathological fractures involve rarely facial bones. When

they occur, they in volve almost always the mandible [4].

Most of trauma mand ibular fractu res involve yo ung male

Figure 1. 3D reconstruction of the CT confirmed the presence

of fracture of the symphyseal region within the neoplastic infil-

tration.

Figure 2. Extraoral view of cutaneous fistula.

B. Abir et al. / Open Journal of Stomatology 3 (2013) 419-424 421

Figure 3. Panoramic radiograph shows pathological fracture in

the mandible body. Changes in the bone structure correspond to

osteoradionecrosis.

Figure 4. 3D reconstruction of the CT confirmed the presence

of a non dislocated fracture in the right body of the mandible.

Figure 5. Panoramic radiograph reveals bone destruction in the

anterior region of the mandible, due to odontogenic cyst.

Figure 6. Postoperative radiograph of after reposition and fixa-

tion with reconstruction locking plate.

Figure 7. Intraoperative view with mandibular reconstruction

by bone graft stabilized with plates.

Figure 8. Four months after surgery, the panoramic radiograph

reveals a proper integration of the bone graft and a good con-

solidation of the fracture.

people. In the opposite, pathological fractures occur in

old patients. Indeed, our data show an increased rate of

pathological mandibular fractures in people over 40

B. Abir et al. / Open Journal of Stomatology 3 (2013) 419-424

422

Figure 9. Intraoperative view of a harvested osteocutaneous

fibula free flap.

years (80% of our series). This might be explained by the

fact that elderly patients are more concerned by malign-

nant conditions and atrophic edentulous jaws [1]. Copes

suggested that spontaneous fractures of the mandible are

often in relation with mastication forces. Anterior man-

dibular fractures are due to the action of depressor mus

cles, while posterior fractures are due to the action of

elevator muscles [5]. In the most cases, osteoradionecro-

sis ORN is suggested as a cause of pathological man-

dibular fractures [2]. ORN occurs after radiotherapy, and

is in relation with hypoxia, hypovascularity and hypo-

cellularity as suggested by the 3H theory of Marx [6].

These phenomena alter bone capacity of reparation. They

occur more often in angular, retromolar and horizontal

parts of mandible because of their unique centromedullar

vascularity. A study including 1000 patients who had

head and neck radiation showed that 2,6% of them de-

veloped ORN, and 23% of these progressed to patho-

logical fracture of mandible [7]. In ORN context, patho-

logical fracture of the mandible is classified as a stage III

ORN by Marx a nd Myers [8].

In this study, ORN comes in the second rank after ma-

lignancies. Oral primary cancer as spinocellular carci-

nomas, or mandibular metastasis are also frequently in-

volved in pathological fractures. Leukaemias, lympho-

mas and especially multiple myeloma are blood produc-

tive system cancers that can cause pathological fractures

of mandible when they concern this bone. It is estimated

that only 1% of malignant tumours found in the oral re-

gion are metastases of breast, prostate, thyroid, kidney or

lung cancer [2]. In fact, the true incidence of metastases

in mandible is unknown, as radiography exam of this

region is not included in systematic survey for metastasis.

Facial bones are less often touched by metastases than

long bones. It seems like it is because of the decrease of

red bone marrow and blood vessels that occurs in the

jaws with age. When they occur, metastases concern

almost always the mandible. This is thought that it is due

to the greater presence of hematopoietic tissue in mandi-

ble than in the other facial bones [9].

Osteomyelitis was also described as a frequent cause

of pathological mandibular fractures. In a 44 patients

study reported by Coletti and Ord [3], osteomyelitis

came in second position (19%) after ORN (49%). Os-

teomyelitis can be associated with implants or third

moral extractions, and there are often causes underlying

predisposing condition such as diabetes.

Biphosphonate related osteonecrosis is a relatively re-

cent recognized pathology, as Marx and other authors

(Wang, Migliorati) [10-12] described the first reports of

this condition in 2003, even if “phossy jaws” cases were

reported more than a century ago. This condition appears

often associated with predisposing pathology as corti-

cotherapy or immunosuppressive treatment, chemother-

apy, osseous diseases, bad nutritional condition or to-

bacco consumption and bad oral condition [11,13]. The

most common clinical presentation is an osteitis occur-

ring after a tooth extraction (86%) [14]. The physiopa-

thology of osteochemonecrosis remains unclear, however

four factors appear to have a role in its occurrence: A)

An accumulation of biphosphonates in the jaw, due to a

fast osseous turnover in relation to the presence of teeth

and the daily activity of jaws. This phenomenon stops

bone remodelling around teeth and periodontal ligament.

B) A high release of cytokines. C) The inhibition of an-

giogenesis and the acceleration of apoptosis. D) The

immunosuppressive condition seen in all patients with a

metastatic disease and under chemotherapy or corticos-

teroids [15].

Iatrogenic condition as a wisdom-tooth extraction can

be the cause of a mandibular fracture. It occurs most

frequently in male patients aged between 25 and 50-year-

old, in the two weeks following surgery [3]. Fractures in

atrophic or long-time edentulous mandible can be seen

after a trauma. However, spontaneous fracture in an

atrophic mandible is an uncommon event. Luhr et al.

[16], defined the atrophic mandible as having less than

20 mm in its body vertical height. In their study include-

ing 84 edentulous patients, they classified atrophic man-

dibles in 3 stages: I) 16 - 20 mm, II) 11 - 15 mm, III) 10

mm or less. Other conditions can also be involved in

pathological fractures of mandible. They can be classi-

fied in different ways.

Treatments of pathological fractures of mandible are

complex because of their multiple aetiologies, their oc-

currence in patients suffering several serious diseases,

and the local bone condition which is very often infected

and non viable. Bone healing in these situations has big

chances to fail, and takes longer time. Treatment strategy

must be adapted to each patient individually. And even if

management strategies are different from aetiology to

another, some rules are common according to Coletti and

Ord’s paper (Figure 10) [3]. A special attention should

be paid to optimize the general health condition of the

patient. Pain, functional and nutritional problems must be

cared, and a soft diet must be started. If a malignant or

B. Abir et al. / Open Journal of Stomatology 3 (2013) 419-424 423

Figure 10. Reconstruction of the mandible with an osteoto-

mized fibula which is affixed to the reconstruction plate.

also a benign disease is present, the treatment of this

condition is considered as a priority. In the cases where

there is no potential for normal union, bone resection

must be performed until arriving to normal bleeding

bone. When there is a sufficient normal bone left, tradi-

tional reduction is performed and rigid fixation is em-

ployed. When a defect is left, the bone continuity is

maintained by reconstruction plates. Reconstruction can

be performed primarily or secondarily, using reconstruct-

tion plates alone, or associated with bone graft taken

from iliac crest for example, or associated with a re-

gional or a micro-vascular composite flap. According to

Pogrel et al. [17], non-vascular bone must be only used

when the osseous defect is less than 6 cm, in a patient

without a history of radiation. It also required an ade-

quate intraoral lining to avoid contact of the bone with

the oral cavity.

In the cases of stage III ORN (Marx & Myers), the

surgical treatment consists on a resection of non viable

tissues. Magnetic resonan ce imaging may help to deline-

ate the extent of marrow involvement to assist the sur-

geon to decide on how much bone requires resection [3].

Another way to determine viable bone is to use tetracy-

cline as proposed by Myers and Marx. Viable bones fixe

the tetracycline, which can be revealed by using Wood’s

light with a wavelength of 365 nm in the ultraviolet

spectrum [8]. Ioannides et al. [18], recommend resec-

tion past 1 cm normal appearing bone, which is recog-

nisable by normal bleeding. If the reconstruction is not

done primarily, a long reconstruction plate or less often

an external fixation can be used. Non viable soft tissues

are excised and soft tissue reparation must be performed

primarily. Thirty to forty hyperbaric oxygen HBO treat-

ments must be proposed before surgery. Ten more HBO

cures are realised after surgery, after what the disease is

classed as a stage IIIR. The reconstruction is now per-

formed secondarily using a bone graft or a composite

flap such as a free fibula flap, and ten more HBO cures

are proposed. Using antibiotic treatments is not system-

atic; however, antibiotics must be necessarily used when

a surgery is proposed on an irradiated mandible [19]. In

anyway, it is important to search a mandibular recurrence

of a cancer, or a spinocellular carcinoma grafted on the

mandible.

The authors have based their management strategies

on their own clinical experience and on the literature data.

In cases of malignant or also benign disease, the disease

process was addressed as a first priority. In cases of ORN,

the bone was excised until normal bleeding was encoun-

tered. The continuity defect created was maintained with

reconstruction plates and then reconstructed primarily or

mostly secondarily. In the few cases where sufficient

bone was left (cysts), a traditional fracture reduction and

a maxillomandibular fixation were performed.

5. CONCLUSION

Pathological fractures are difficult to treat because of

their diverse aetiologies and the impact will have relation

to normal bone healing. Treatment must take the local

and overall condition of the patient into consideration.

Free flap reconstruction should be considered when pos-

sible, especially in cases secondary to osteoradionecrosis

or malignancies.

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