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Pathological fracture of the mandible
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  1. David M McGoldrick1,
  2. Caroline McCarthy2,
  3. Duncan Sleeman2
  1. 1Department of Maxillofacial Surgery, Cork University Hospital, Cork, Ireland
  2. 2Cork University Dental Hospital, Cork, Ireland
  1. Correspondence to Dr David M McGoldrick, davidmcgoldrick{at}gmail.com

https://doi.org/10.1136/bcr-2014-208487

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    Description

    A 45-year-old man attended the oral surgery department with swelling and pain 10 days postsurgical removal of two impacted teeth in his left mandible, following a 3-year history of recurrent infection (figure 1). The surgery had been uneventful. The occlusion and continuity of the mandibular border was confirmed postoperatively but only a thin border remained.

    Figure 1
    Figure 1

    Orthopantomograph displaying impacted teeth in mandibular body.

    Seven days post extraction he had felt ‘a crack’ in his jaw while eating, despite folllowing a soft diet. He had pain and swelling in the area of the extraction and a palpable step, not previously present, in the mandibular rim. He also had an altered occlusion and hypoanaesthesia of his left mental region. An orthopantomograph indicated a pathological fracture (figure 2). This was later treated with open reduction and internal fixation via an external approach to avoid the pathology and improve access to bone available for fixation (figures 3 and 4). The patient was also placed in intermaxillary fixation postoperatively to aid healing.

    Figure 2
    Figure 2

    Orthopantomograph displaying pathological fracture of left body of mandible.

    Figure 3
    Figure 3

    Intraoperative image of fracture repair with limited bone available.

    Figure 4
    Figure 4

    Postoperative orthopantomograph of fracture reduction and plating.

    Pathological fracture of the mandible is rare, accounting for between 1% and 2% of fractures in some reports.1 Common causal factors include surgical procedures, osteonecrosis of the jaw, infection and tumours.2 ,3 Treatment of pathological fractures is difficult as bone is often limited or compromised by the pathology, making fixation difficult.2 This case provided a clinical dilemma as recurrent infection had meant the patient requested the initial high-risk surgery. The risk of fracture both iatrogenically and postoperatively was apparent, and, unfortunately, occurred in the postoperative period. However, a satisfactory result was ultimately achieved.

    Learning points

    • Pathological mandibular fractures are rare.

    • Treatment is often difficult due to the coexisting pathology.

    • The increased risk of fracture when removing lower third molars, which will result in a thin mandibular border, should be outlined to the patient.

    References

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      1. Gerhards F,
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      3. Wagner W
      . Pathological fractures of the mandible. A review of the etiology and treatment. Int J Oral Maxillofac Surg 1998;27:186–90. doi:10.1016/S0901-5027(98)80007-6
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      1. Grau-Manclús V,
      2. Gargallo-Albiol J,
      3. Almendros-Marqués N, et al
      . Mandibular fractures related to the surgical extraction of impacted lower third molars: a report of 11 cases. J Oral Maxillofac Surg 2011;69:1286–90. doi:10.1016/j.joms.2010.05.059
      OpenUrlCrossRefPubMed
    View Abstract

    Footnotes

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.