Spontaneous Mandibular Fracture in A Partially Edentulous Patient: Case Report

P
R A T I Q U E
C L I N I Q U E
Spontaneous Mandibular Fracture in a

Partially Edentulous Patient: Case Report
(Fracture mandibulaire spontane chez un patient partiellement dent : tude de cas)
Philippe Libersa, DMD, PhD

David Roze, DMD
Thierry Dumousseau, MD
S o m m a i r e
Larticle dcrit le cas dun patient de 78 ans prsentant une fracture de la mandibule traite par miniplaque
dostosynthse. la suite du premier traitement, une radiographie panoramique rvle une fracture de la miniplaque, et au suivi, un dvissage partiel de la plaque de substitution. Pour le praticien dentaire, ce cas clinique
souligne limportance de la radiographie panoramique, de lanalyse et de lquilibration occlusales pour le diagnostic de la fracture mandibulaire, lvaluation de la fracture de la miniplaque et le traitement, surtout en labsence de
traumatisme.
Mots cls MeSH : fractures, spontaneous/surgery; mandibular fractures; postoperative complications
J Can Dent Assoc 2003; 69(7):42830
Cet article a fait lobjet dune rvision par des pairs.
he mandible is the most commonly fractured bone of

the face because of its prominent and exposed
position.1 It is the only moving bone of the facial
skeleton, and its physiological functions must be considered in
the treatment of trauma.2 The most common mechanisms of
injury to this bone include motor vehicle crashes, falls, fights,
sports injuries and removal of the third molar.3 Spontaneous
fractures without an obvious cause are rare.
Treatment methods include closed reduction with maxillomandibular fixation (Gunning splint), closed reduction
without maxillomandibular fixation, and open reduction and
fixation with interosseous wires or screws and plates.4
This report presents a case of spontaneous mandibular
fracture subsequent to placement of a new denture, as well as
fracture of the miniplate used to reduce the original fracture.
Case Report
An almost totally edentulous 78-year-old man without a
significant dental history was admitted to hospital with a large,
hard edema in the left lateral mandibular area. Fifteen days
before being admitted to hospital, the patient had consulted
his dentist with pain and swelling of the left mandibular
428
Juillet/Aot 2003, Vol. 69, N 7
region. The only treatment provided by his dentist at that time

was a course of antibiotics, which had been ineffectual.
Clinical examination revealed impaired function and mobility, as well as severe edema.
Panoramic radiographic examination showed a displaced
mandibular fracture and bone radiolucency in the left second
molar area (Fig. 1). During surgery to repair the fracture, a
biopsy sample for later analysis was taken from the area where
the bone appeared radiolucent on the panoramic radiographs,
as immediate histological examination seemed unnecessary.
Treatment by Gunning splints seemed to be the treatment
of choice, to avoid the risk of aseptic necrosis of the mandible.
However, this method of treatment was impossible in this case
because the mandibular fracture was 2 weeks old, and the
massive edema would have prevented correct placement of the
denture on the mandibular ridge. Therefore, the fracture was
reduced by an intraoral open reduction and was stabilized with
a titanium miniplate. The fracture site was stabilized with
special forceps, and monocortical titanium screws were placed
on each side of the fracture. During this reduction, the mandibular incisors, which had a questionable prognosis, were not
extracted, because the patient had recently been fitted with a
Journal de lAssociation dentaire canadienne
Spontaneous Mandibular Fracture in a Partially Edentulous Patient
Figure 1: Panoramic radiograph demonstrates displacement of the fragments of mandibular

bone.
Figure 2: Panoramic radiograph of the patient 3 weeks after fracture reduction shows
miniplate fracture.
fractured (Fig. 2). It was presumed that this

fracture might have occurred because of an
internal defect in the miniplate, as the
patient had complied strictly with his
postoperative instructions and had been
unaware of any cracking sound while using
the mandible. A second surgical procedure
was performed to remove the defective
miniplate, which was replaced by another
plate of the same design. Postoperative
panoramic radiography confirmed that the
miniplate and the screws were well placed
in the mandibular bone. Eight days later,
follow-up panoramic radiography showed
that one of the monocortical screws immediately adjacent to the fracture had become
partially unscrewed. This development
suggested that unusually strong forces were
being exerted in this area.
During precise questioning, the patient
reported that a new upper and lower
denture had been fitted 2 weeks before
the mandibular fracture. He had continued
wearing the new upper denture day and
night after the fracture reduction. After
consultation, it was decided to delay further
surgery, as the displacement of the screws
was limited. However, the patient was asked
to refrain from wearing his maxillary
denture at any time.
Two months later, radiographic examination confirmed the formation of a bone
callus. Three months later, the remaining
lower anterior teeth were extracted. After
1 year, a complete head and neck examination showed the stability of the fracture
segments, and panoramic radiography
confirmed good bone healing (Fig. 3).
Discussion
Although the mandible is membranous
during its embryonic stage, its physical
structure resembles a bent long bone,5 and
Figure 3: Panoramic radiograph of the patient 1 year later confirms good bone healing.
it is subject to biomechanical compression,
bending, torsion and traction.6 This arch of
corticocancellous bone projects downward
new partial lower and upper denture. Histological examination
and forward from the base of the skull and constitutes the
revealed a nonmalignant osteitis lesion.
strongest and most rigid component of the facial skeleton.
Postoperative panoramic radiography demonstrated satisHowever, it is more commonly fractured than the other
factory reduction of the fracture. The patient was advised to
bones of the face, and the teeth or lack thereof may be the
eat a liquid diet for 2 days, followed by a diet of soft food for
most important factor in determining where fractures occur.
6 weeks.
Other factors that can influence fractures are the forces exerted
Temporary paresthesia of the left mandibular area
by the muscles of mastication, the occlusal loading pattern
disappeared progressively. Twenty-one days after the surgery,
and the osseous anatomy. Fractures of the edentulous mandithe patient noticed renewed pain in the same area, and panorable most often occur in elderly people. As the patient ages,
bony strength is reduced. According to Thaller,7 there is no
mic radiography revealed that the titanium miniplate had
429
Libersa, Roze, Dumousseau
definitive recommendation for either closed or open reduction

in cases of fracture in the edentulous mandible. In the case
reported here, Gunning splints could not be used, so osteosynthesis of the fractured edentulous mandible was achieved
by means of miniplates and monocortical screws. Bicortical
screwing would be preferred from the perspectives of infection
and pseudarthrothis,8 however, monocortical screwing causes
fewer occlusal disorders. When troubles exist, they are minor,
and only rarely is a second procedure required.9,10
Complications may occur in miniplate osteosynthesis of
mandibular fracture, but miniplate fractures are rare (occurring in 0.8% to 2% of cases, according to Edwards and
others11) and are generally due to noncompliance with
instructions to eat a soft diet for 4 to 6 weeks.
The present case emphasizes 2 important aspects of treatment: (1) radiography for diagnosis and evaluation of mandibular fracture and treatment and (2) occlusal analysis and
stabilization.12
Panoramic radiography is a standard clinical procedure for
the evaluation of oral abnormalities, such as spontaneous
edema in an edentulous area, especially when the patient does
not report a specific precipitating event.
In the case reported here, panoramic radiography revealed
a mandibular fracture with radiolucency in the fracture area.
After fracture repair, postoperative panoramic radiography is
recommended.13 In this case, the miniplate fracture suspected
clinically was confirmed by panoramic radiography. A latter
panoramic radiograph (after the second surgical reduction)
showed that one of the monocortical screws had become
unscrewed and also contributed to the diagnosis of this
complication. Finally, the radiography confirmed the reduction of the fracture and formation of bone callus.
This case also underlines the importance of occlusal analysis before prosthetic rehabilitation and before treatment of a
mandibular fracture. In a partially or totally edentulous
patient with maxillary or mandibular dentures (or both),
maximum occlusal forces are reduced; however, imperfect
occlusion can still induce mandibular fracture, especially in a
patient with mandibular atrophy. According to Barber and
others14 and Childress and Newlands,12 the goal of mandibular fracture repair is good occlusion, as illustrated by this case.
In this case, imperfect occlusion between the 3 remaining
mandibular anterior teeth and the new maxillary denture
seems to have been the main cause of fracture of the atrophic
mandible, as well as the fracture of the miniplate osteosynthesis after reduction.
This patient did not report hearing any characteristic cracking sounds while eating or after surgery. He also carefully
followed the recommended diet. Therefore, it is surmised that
nocturnal bruxist forces were responsible for these fractures.
When these occlusal forces were removed, secondary osseointegration and satisfactory union were achieved without further
surgery, despite the unscrewing of the monocortical screw.
A new denture was fitted 9 months later, and total function
and esthetic appearance were restored. C
430
Le Dr Libersa est charg de cours, Dpartement de mdecine dentaire,

Centre Abel Caumartin, Centre hospitalier rgional universitaire
de Lille, France.
Le Dr Roze est membre du personnel, Dpartement de mdecine
dentaire, Centre Abel Caumartin, Centre hospitalier rgional
universitaire de Lille, France.
Le Dr Dumousseau est spcialiste en chirurgie buccale et stomatologie
maxillofaciale, Centre hospitalier de Seclin, France.
crire au : Dr Philippe Libersa, 60, la posterie, 59830 Bourghelles,
France. Courriel : [email protected].
Les auteurs nont aucun intrt financier dclar.
Rfrences
1. Banks P. Killeys fractures of the mandible. 4th ed. London:
Butterworth-Heineman Wright; 1991. p. 1112.
2. Archer WH. Fractures of the facial bones and their treatment. In:
Archer WH, editors. Oral and maxillofacial surgery. 5th ed. Philadelphila: WB Saunders; 1975. p. 25960.
3. Iatrou I, Samaras C, Theologie-Lygidakis N. Miniplate osteosynthesis
for fractures of the edentulous mandible: a clinical study 198996.
J Craniomaxillofac Surg 1998; 26(6):4004.
4. Joos V, Meyer U, Tkotz T, Weingart D. Use of mandibular fracture
score to predict the development of complications. J Oral Maxillofac Surg
1999; 57(1):25.
5. Maaita J, Alwrikat A. Is the mandibular third molar a risk factor for
mandibular angle fracture? Oral Surg Oral Med Oral Patho Oral Radiol
Endod 2000; 89(2):1436.
6. Gola R, Cheynet F, Carreau JP, Guyot L. [The value of an osteosynthesis arch-plate combination in the application zone in the treatment of
fractures of the body of the mandible.] Intrt de lassociation arc-plaque
dostosynthse en zone utile dans le traitement des fractures du corpus
de la mandibule. Rev Stomatol Chir Maxillofac 1996; 97(2):7283.
7. Thaller SR. Fractures of the edentulous mandible: a retrospective
review. J Craniofac Surg 1993; 4(2):914.
8. Jammet P, Souyris F, Atlan G, Dupoirieux L. [A comparative study of
2 series of mandibular osteosynthesis using screwed plates.] tude
comparative de deux sries dostosynthses mandibulaires par plaques
visses. Rev Stomatol Chir Maxillofac 1992; 93(2):769.
9. Peled M, Laufer D, Helman J, Gutman D. Treatment of mandibular
fractures by means of compression osteosynthesis. J Oral Maxillofac Surg
1989; 47(6):5669.
10. Souyris F, Lamarche JP, Mirfakhrai A. Treatment of mandibular fractures by intraoral placement of bone plates. J Oral Surg 1980;
38(1):335.
11. Edwards TJ, David DJ, Simpson DA, Abbott AH. The relationship
between fracture severity and complication rate in miniplate osteosynthesis of mandibular fractures. Br J Plast Surg 1994; 47(5):3101.
12. Childress SC, Newlands SD. Utilization of panoramic radiographs to
evaluate short-term complications of mandibular fracture repair. Laryngoscope 1999; 109(8):126972.
13. Kawai T, Murakami S, Hiranuma H, Sakuda M. Radiographic changes during bone healing after mandible fractures. Br J Oral Maxillofac
Surg 1997; 35(5):3128.
14. Barber HD, Woodbury SC, Silverstein KE, Fonseca RJ. Mandibular
fractures. In: Fonseca RJ, Walker RV, Betts NJ, Barber HD, editors. Oral
and maxillofacial trauma. Philadelphia: WB Saunders; 1997. p. 473526.

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P

Spontaneous Mandibular Fracture in a

Philippe Libersa, DMD, PhD

he mandible is the most commonly fractured bone of

Juillet/Aot 2003, Vol. 69, N 7

region. The only treatment provided by his dentist at that time

Spontaneous Mandibular Fracture in a Partially Edentulous Patient

Figure 1: Panoramic radiograph demonstrates displacement of the fragments of mandibular

fractured (Fig. 2). It was presumed that this

Juillet/Aot 2003, Vol. 69, N 7

Libersa, Roze, Dumousseau

definitive recommendation for either closed or open reduction

Juillet/Aot 2003, Vol. 69, N 7

Le Dr Libersa est charg de cours, Dpartement de mdecine dentaire,

Journal de lAssociation dentaire canadienne

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