|Year : 2010 | Volume
| Issue : 3 | Page : 324-326
Spontaneous bilateral fracture of the mandible: A case report and review of literature
Muttagi Sidramesh, Pankaj Chaturvedi, Devendra Chaukar, Anil K D'Cruz
Surgical Oncology (Head & Neck Services), Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
|Date of Web Publication||29-Nov-2010|
Surgical Oncology (Head & Neck Services), Tata Memorial Hospital, Parel, Mumbai - 400 012, Maharashtra
Several mechanisms have been described in the literature for mandibular fractures. However, it is to be noted that fracture of mandible can occur spontaneously, especially in elderly persons with atrophic edentulous mandible. It is important to rule out local and systemic factors that can be the possible causes for fractures in these cases. We describe a case of spontaneous fracture of the mandible in an elderly lady with a review on possible mechanisms that can result in such fractures.
Keywords: Atrophic, edentulous, fracture, mandible, spontaneous
|How to cite this article:|
Sidramesh M, Chaturvedi P, Chaukar D, D'Cruz AK. Spontaneous bilateral fracture of the mandible: A case report and review of literature. J Can Res Ther 2010;6:324-6
|How to cite this URL:|
Sidramesh M, Chaturvedi P, Chaukar D, D'Cruz AK. Spontaneous bilateral fracture of the mandible: A case report and review of literature. J Can Res Ther [serial online] 2010 [cited 2015 Jan 29];6:324-6. Available from: http://www.cancerjournal.net/text.asp?2010/6/3/324/73343
| > Introduction|| |
Mandible is the most commonly fractured bone in the maxillofacial skeleton owing to its prominence and exposure to injury.  The most common mechanisms of injury to this bone include motor vehicle crashes, falls, fights, sports injuries and removal of the third molar. 
Spontaneous occurrence of mandibular fracture has been described in the literature in association with progressive systemic sclerosis and most often in association with local cause like infection of sublingual gland, osteomyelitis, hemiatrophy of mandible and other jaw pathological conditions. ,,,,
Here we report a case of spontaneous bilateral fracture of edentulous mandible which on a systematic work up turned out to be idiopathic.
| > Case Report|| |
A 68-year-old lady was referred to head and neck services of our tertiary cancer institute with a complaint of inability to close her mouth completely since one month. She did not have any pain or discomfort associated with her chief complaint and reported that she had a sudden onset of this problem. Her medical history was not significant. She had got her teeth extracted 20 years back due to caries and mobility. She claimed that she was not a denture wearer.
On extraoral examination, there was no tenderness or swelling. Intraorally, there was no hematoma or laceration over the oral mucosa. Only finding was loss of continuity of mandibular arch palpable bilaterally in canine-premolar region and abnormal mobility of discontinuous fragments. There was an anterior open bite with a gap of 2.2 cm in the midline between maxillary and mandibular alveolar ridges.
Digital panoramic view revealed bilateral body fracture of the mandible with the possibility of fibrous union of the fragments in an atrophic edentulous mandible [Figure 1].
|Figure 1: Digital panoramic view showing bilateral body fracture of the mandible with the possibility of fibrous union of the fragments in an atropic edentulous mandible|
Click here to view
As the patient was asymptomatic, she refused treatment and further investigation, the patient was asked to take soft diet and advised follow up. She was followed up for six months and continued to be asymptomatic. There was nothing obvious on clinical examination.
| > Discussion|| |
In the absence of obvious etiology, it is difficult to explain the occurrence of mandibular fractures. However, edentulousness and increased age have been important risk factors in such cases that have been reported.  More incidents have been reported in females. Spontaneous fractures of long bones have been described in nursing home residents who were elderly females between 80 and 90 years of age.  Femur was the most common bone that was reported to have highest incidence of spontaneous fracture followed by tibia and fibula. There were definite risk factors in these patients that contributed to spontaneous fractures. These included bedridden patients, long-term feeding by Ryle's tube, cerebrovascular accidents, hemiplegia, dementia and lower limb contractures. In addition to this, osteoporosis is an important factor that can contribute to weakening of bones in older women.  In the skeleton in general, spontaneous fractures are much more common in women over the age of 50 than in men of similar age and undoubtedly this has a connection with post-menopausal osteoporosis.  However, it has been found that in the mandible cortical porosity is independent of sex.  Thus, osteoporosis may not be as important in the etiology of mandibular fractures in female patients as general skeletal considerations suggest.
More often, spontaneous fracture of the mandible has been known to occur in the area of genial tubercles, especially in elderly females with atrophic edentulous mandibles.  It appears that fracture of the genial tubercles in an atrophied mandible can occur under normal masticatory forces, which are delivered through the mandibular denture. In all these reports, patients have presented with symptoms like pain, swelling and hematoma in the floor of the mouth, limitation in tongue mobility and dysphagia. In our case, absence of symptoms was an interesting finding.
Abnormal muscular activity and inability of atrophic edentulous mandible to sustain the muscular forces have been recognized as causes of spontaneous mandible fracture.
Muscular activity may also lead to a spontaneous fracture by subjecting bone to repeated stress. In the senile skeleton, there is also an increase in the proportion of mineral salts to ground substance making the bone more brittle and prone to fracture. , Pathological conditions like benign and malignant tumors or metastasis should be considered in such cases. The patient was referred to us to rule out the cause of such fracture suspecting it to be associated with malignancy. In this case, there was no clinical and radiological evidence of such condition and the patient was asymptomatic and comfortable with soft diet. Her clinical examination and investigations did not reveal any local or systemic factor responsible for mandible fracture. The only significant finding was severely atrophic edentulous mandible.
Various modalities have been utilized in the treatment of these patients ranging from conservative regimes, miniplate osteosynthesis, use of rib grafts, other autogenous bone grafts, distraction osteogenesis and microvascular free flap reconstruction in the treatment of the fractured atrophic edentulous mandible. ,,,, None of these methods is entirely satisfactory with some series reporting mal-union or nonunion rates in the range of 25-40%. 
In view of asymptomatic occurrence of this fracture in an elderly frail lady, severe atrophic changes in the bone and patient's refusal for further treatment, we preferred to avoid any active treatment and kept her under observation.
Thus, we conclude that spontaneous fracture of the mandible can occur uncommonly in elderly subjects, even in the absence of any pathology, in severely atrophic mandible. In absence of the underlying pathology, it may be observed without any active treatment especially in an asymptomatic elderly patient.
| > References|| |
|1.||Banks P. Killey's fractures of the mandible. 4 th ed. London: Butterworth-Heineman Wright; 1991. p. 1-112. |
|2.||Iatrou I, Samaras C, Theologie-Lygidakis N. Miniplate osteosynthesis for fractures of the edentulous mandible: A clinical study 1989-96. J Craniomaxillofac Surg 1998;26:400-4. |
|3.||Hiroshi M, Kunio I. Progressive systemic sclerosis with spontaneous fracture due to resorption of the mandible: A case report. J Oral Maxillofac Surg 2006;64:1137-9. |
|4.||Fleming WE, Cook RM, Hueston JT. A case of spontaneous fracture of the mandible associated with infection of the right sub-lingual gland. Aust Dent J 1967;12:360-3. |
|5.||Kelly DE, Harrigan WF. An unusual bilateral pathological fracture. J Oral Surg 1977;35:48-50. |
|6.||de Silva BG. Spontaneous fracture of the mandible following third molar removal. Br Dent J 1984;156:19-20. |
|7.||Bramley P, Forbes A. A case of progressive hemiatrophy presenting with spontaneous fractures of the lower jaw. Br Med J 1960;1:1476-8. |
|8.||Cope MR. Spontaneous fracture of an atrophic edentulous mandible treated without fixation. Br J Oral Surg 1982:20:22-30. |
|9.||Wong TC, Wu WC, Cheng HS, Cheng YC, Yam SK. Spontaneous fractures in nursing home residents. Hong Kong Med J 2007;13:427-9. |
|10.||Meema HE. Cortical bone atrophy and osteoporosis as a manifestation of aging. Am J Roentgenol Radium Ther Nucl Med 1963;89:1287-95. |
|11.||Devas M. Stress Fractures. Edinburgh, London and New York: Churchill Livingstone. p. 1 18 |
|12.||Von Wowern N, Stoltze K. Sex and age differences in bone morphology of mandibles. Scand J Dent Res 1978;86:478-85. |
|13.||Gallego L, Junquera L, Villarreal P, de Vicente JC. Spontaneous fracture of the mandibular genial tubercles. A case report. Med Oral Patol Oral Cir Bucal 2007;12:E599-601. |
|14.||Jowsey J. Age changes in human bone. Clin Orthop 1960;17:210. |
|15.||Alty HM. Atrophy of the mandible and spontaneous fracture. A report of two cases. Br Dent J 1963;114:188. |
|16.||Bruce R, Strachen D. Fracture of the edentulous mandible. J Oral Surg 1976;34:973-9. |
|17.||Thraller SR. Fractures of the edentulous mandible: A retrospective review. J Craniofac Surg 1993;4:91-4. |
|18.||Bruce RA, Ellis E. The second Chalmers J Lyons Academy study of fractures of the edentulous mandible. J Oral Maxillofac Surg 1993;51:904-11. |
|19.||Coletti D, Ord RA. Treatment rationale for pathological fractures of the mandible: A series of 44 fractures. Int J Oral Maxillofac Surg 2008;37:215-22. |
|20.||Saulacic N, Iizuka T, Martin MS, Garcia AG. Alveolar distraction osteogenesis: A systemic review. Int J Oral Maxillofac Surg 2008;37:1-7. |
|This article has been cited by|
||Fluorescence imaging for the detection of early neoplasia in Barrett’s esophagus
| ||David F. Boerwinkel,M. Kareem Shariff,Massimiliano di Pietro,Jasmin A. Holz,Maurice C. Aalders,Wouter L. Curvers,Rebecca C. Fitzgerald,Jacques J. Bergman |
| ||European Journal of Gastroenterology & Hepatology. 2014; 26(7): 691 |
||Optimized endoscopic autofluorescence spectroscopy for the identification of premalignant lesions in Barrett’s oesophagus
| ||Jasmin A. Holz,David F. Boerwinkel,Sybren L. Meijer,Mike Visser,Ton G. van Leeuwen,Maurice C.G. Aalders,Jacques J.G.H.M. Bergman |
| ||European Journal of Gastroenterology & Hepatology. 2013; 25(12): 1442 |