Open Journal of Stomatology, 2013, 3, 419-424 OJST Published Online November 2013 (
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
Received 30 October 2012; revised 15 October 2013; accepted 26 October 2013
Copyright © 2013 Badreddine Abir et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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
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.
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.
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
B. Abir et al. / Open Journal of Stomatology 3 (2013) 419-424
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
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
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
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-
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-
Figure 2. Extraoral view of cutaneous fistula.
Copyright © 2013 SciRes. OPEN ACCESS
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
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
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B. Abir et al. / Open Journal of Stomatology 3 (2013) 419-424
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
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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
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.
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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