Arch Health Invest (2021)10(4):637-640 © 2021 - ISSN 2317-3009

http://dx.doi.org/10.21270/archi.v10i4.4942 Clinical Case

Pathological fracture of the jaw due to osteomyelitis after a third molar extraction
Fratura patológica da mandíbula devido a osteomielite após extração do terceiro molar
Fractura patológica de la mandíbula debido a osteomielitis después de la extracción del tercer molar
Thais PIMENTEL, DDS, MSc1
Henrique HADAD, DDS, MSc1
Laís Kawamata de JESUS, DDS1
Luara Teixeira COLOMBO, DDS, MSc1
Albertino Gomes ALCANTARA, DDS2
Francisley Ávila SOUZA, DDS, MSc, PhD1
Idelmo Rangel GARCIA-JÚNIOR, DDS, MSc, PhD1
1
Department of Surgery and Integrated Clinic, São Paulo State University (UNESP), School of Dentistry, Araçatuba
2
Department of Surgery, Rio de Janeiro State University (UERJ), Rio de Janeiro-RJ, Brazil
Abstract
The osteomyelitis is an inflammatory process in bone tissue caused by an infection, commonly related to anaerobic pathogens,
frequently Staphylococcus aureus and Streptococcus sp. Several causes have been related such as dentoalveolar infection,
trauma, radiation and genetic condition, but it is not common after surgery for third molar extractions, especially in healthy
patients. The symptoms of chronic osteomyelitis usually include signs and symptoms such as pain, edema, suppuration, areas
of bone sequestration, and limited mouth opening. Among the complications associated with this condition, pathological fracture
may occur due to local bone fragility. This paper aimed to report a rare case of pathological mandible fracture due to
osteomyelitis after third molar extraction in a healthy male patient treated by a surgical procedure. The procedure consisted of
decortication and resection of the sclerotic bone followed by reduce and fixation of mandibular fracture with one 2.4
reconstructive plate and one 2.0 plate with standard screws.
Descriptors: Chronic Disease; Osteomyelitis; Mandible.
Resumo
A osteomielite é um processo inflamatório no tecido ósseo causado por uma infecção, comumente relacionada a patógenos
anaeróbicos, freqüentemente Staphylococcus aureus e Streptococcus sp. Várias causas têm sido relacionadas, como infecção
dentoalveolar, trauma, radiação e condição genética, não sendo comum após cirurgia para extrações de terceiros molares,
principalmente em pacientes saudáveis. Os sintomas da osteomielite crônica geralmente incluem sinais e sintomas como dor,
edema, supuração, áreas de sequestro ósseo e abertura limitada da boca. Entre as complicações associadas a essa condição,
pode ocorrer fratura patológica devido à fragilidade óssea local. Esse artigo objetivou relatar um caso raro de fratura patol ógica
de mandíbula devido a osteomielite após extração de terceiros molares em um paciente do sexo masculino saudável e discutir
o tratamento proposto. O procedimento consistiu em decorticação e ressecção do osso esclerótico, seguido de redução e
fixação da fratura da mandíbula com uma placa 2.4 de reconstrução e uma placa 2.0 com parafusos padrão.
Descritores: Doença Crônica; Osteomielite; Mandíbula.
Resumen
La osteomielitis es un proceso inflamatorio en el tejido óseo causado por una infección, comúnmente relacionada con
patógenos anaerobios, a menudo Staphylococcus aureus y Streptococcus sp. Se han relacionado varias causas, como
infección dentoalveolar, trauma, radiación y afección genética; No es común después de la cirugía para la extracción de
terceros molares, especialmente en pacientes sanos. Los síntomas de la osteomielitis crónica generalmente incluyen signos y
síntomas como dolor, edema, supuración, áreas de secuestro óseo y apertura bucal limitada. Entre las complicaciones
asociadas con esta afección, puede ocurrir fractura patológica debido a la fragilidad ósea local. Este estudio tuvo como objetivo
informar un caso raro de fractura patológica de la mandíbula debido a osteomielitis después de la extracción de terceros
molares en un paciente masculino sano tratado con un procedimiento quirúrgico. El procedimiento consistió en decorticación y
resección del hueso esclerótico, seguido de reducción y fijación de la fractura mandibular con una placa de reconstrucción 2.4 y
una placa 2.0 con tornillos estándar.
Descriptores: Enfermedad Crónica; Osteomielitis; Mandíbula.
INTRODUCTION
The extraction of impacted third molars is pain, edema, suppuration, areas of bone
one of the most common procedure performed sequestration, and limited mouth opening, which
in oral and maxillofacial surgery. The reasons for can often be masked by self-medicating
extracting these teeth include pericoronitis, patients4. In most cases the causative
cysts, periodontal problems, carious lesion on pathogens are anaerobic and the most
third or second molar1. Osteomyelitis of the jaw frequently found microorganism are
after the extraction of a tooth are a rare Staphylococcus aureus (over 60%),
complication, with few reports in the literature2. Peptostreptococcus species, and Pseudomonas
Osteomyelitis is an inflammation, usually aeruginosa, among others5.
of infectious origin that invades the bone and its The removal of bone sequestrations,
medullary spaces. Several causes have been lesion debridement, bone decorticalization,
related, such as dentoalveolar infection, trauma, associated with the systemic use of
radiation and genetic condition. Rare in healthy antimicrobials, usually of broad spectrum of
patients, it is usually associated with alcohol action, are the main points addressed for the
consumption, smoking, uncontrolled diabetes treatment of these infectious conditions6. Thus,
and immunosuppressive diseases3. this this paper aimed to report an unfortunate
The symptoms of chronic osteomyelitis development of osteomyelitis in a healthy man
usually include signs and symptoms such as after removal of an impacted third molar.

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Arch Health Invest (2021)10(4):637-640 © 2021 - ISSN 2317-3009
http://dx.doi.org/10.21270/archi.v10i4.4942

CLINICAL CASE pain and trismus with a maximum interincisal

A 55 years old male patient, healthy opening of 20mm. During clinical examination it
patient presented to the office with a primary was seen that the socket was exposed without
complaining of pain, swelling and unpleasant any kind of exudate and left mandible angle had
smell and taste in the mouth for the last month a slight motility. Radiographic examination
(Figure 1a, b, c). His medical history revealed he included a new CT scan and revealed an
was not using any regular medication, had no extensive osteolytic mandibular lesion and a
known allergies and had never smoked. pathological fracture of mandible angle, which
On intraoral examination, signs of chronic suggested chronic osteomyelitis (Figure 4).
inflammation and carious lesion were seen
associated with the left lower second and third
molar that was in infra occlusion. On
radiographic examination an intimate
relationship between the teeth and the inferior
alveolar and a very narrow mandible below them
was verified (Figure 1d).

Figure 2: Anatomic reconstruction from CT scan. Lateral (A) and

Medial (B) view.

Figure 1: Clinical presentation of the patient in profile and frontal

view (A, B and C), and panoramic section from CT scan.

Due to the narrow basilar mandible and

the chance of hemorrhage, dental extraction
was performed under general anesthesia with
rigid internal fixation material available to be
used in case of mandible fracture. The
procedure occurred as a regular extraction with
the detachment performed antero-posteriorly,
avoiding extension beyond the external oblique Figure 3: Panoramic section from CT scan in immediate
line. Osteotomy was performed in a minimally postoperative
invasive manner to avoid mandible fracture,
followed by tooth section with surgical drills, both
accompanied by copious irrigation with saline
solution. After the extraction the socket was
filled with Bio-Oss and primary closure was
achieved using Vycril thread 3.0 suture.
Antibiotics and painkillers were prescribed after
surgery: Amoxicillin and clavulanic acid 875mg
every 12 hours for 7 days, 400 mg of Ibuprofen
every 6 hours and 750 mg of acetaminophen
every 6 hours both for 5 days after surgery. The
patients return for follow-up without any
complain and healing was progressing as usual.
A posteoperative CT scan was performed
(Figures 2 and 3). Figure 4: Panoramic section from CT scan in 3-month follow-up
Three months postoperatively the patient highlighting an osteolytic mandibular lesion with pathological
fracture in the mandible angle.
returned for a follow up and reported severe
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Based on the clinical history, the patient prescribed. Eight months after surgery patient is
was hospitalized to start venous antibiotic still under regular follow-up reported no further
therapy and undergo to a surgical procedure to symptoms of pain or bad taste in mouth and in
reduce and fix the mandibular fracture. Before CT scan is possible to see new bone formation
starting venous antibiotic therapy, material was on the fractured line (Figures 5b and 6b).
collected from the surgical site for DISCUSSION
microbiological and histopathological analysis.
The surgical procedure consisted of Chronic osteomyelitis is a term used to
decortication and resection of the sclerotic bone describe an infectious inflammatory disease of
followed by reduce and fixation of mandibular the bone marrow. The remodeling bone is
fracture with one 2.4 reconstructive plate and compromised because the osseous blood
one 2.0 plate with standard screws. The patient supply is diminished by an inflammatory
would not to tolerate a scar in his face, so the exudate. Several local and systemic factors
reconstructive plate was placed intraorally have been suggested to the development of
(Figures 5a and 6a). osteomyelitis, but it is a rare condition in healthy
patient, such as the patient in this report3.
Common complications after third molar
surgeries are alveolar osteitis, infection,
neurological injuries and hemorrhage.
Osteomyelitis of the jaw after the extraction of a
tooth are a complication, with few reports in the
literature7. A previously paper published
evaluated the complications after third molar
surgery and between 101 complications in 1,199
wisdom teeth extraction, none of them were for
osteomyelitis8. Another one, evaluated 55 third
molar complications who required hospitalization
and only one of them was caused by
osteomyelitis9.
Figure 5: Anatomic reconstruction from CT scan after surgery There are some case reports10,11 of
from reconstruction. Immediate postoperative (A) and 8-month pathologic fractures of the mandible caused by
follow-up (B). osteomyelitis most of the fractures are caused
by lesions, which are characterized by an
aggressive osteolysis. In this case, there was an
extensive and fast osteolysis that could be may
have been caused by a fissured fracture at the
time of the surgery that created an infected in
the surrounding area or an asymptomatic
infection with microorganisms that do not
respond to regular prescribed antibiotic
treatment after third molar extraction.
The microbiota associated with
osteomyelitis may be variable, since in addition
to the local microorganisms, it will present the
dissemination of microorganisms associated
with its etiology, such as odontogenic,
endodontic infections, gingivitis, periodontitis,
periimplantitis and pericoronitis. The
Figure 6: Panoramic section from CT scan after surgery from
microbiological and histopathological analysis of
reconstruction. Immediate postoperative (A) and 8-month follow-up the associated pathogens becomes even more
(B). important in these cases, being responsible for
The results from the sample showed defining the type of antibiotic that should be
evidence of bone trabeculae without osteocytes used, as well as the conduct performed in the
permeated by mixed inflammatory infiltrate and reported case12.
colonies of enterobacter cloacae and Different opinions regarding the most
streptococcus oralis. After surgery ciprofloxacin appropriate treatment can be found in the
500mg every 12 hours and clindamycin 300mg literature, although hyperbaric oxygen therapy
every 6 hour both for a period of 3 month was and antibiotics may be effective, but they are an

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adjuvant therapy, elimination of the infectious a late implant failure: a clinical report. J
cause is mandatory. In this case the main Prosthet Dent. 2006;95:106-10.
treatment was the decortication and resection of 11. González-Navarro B, Arranz-Obispo C,
the sclerotic bone with intern rigid fixation of the Albuquerque R, Jané-Salas E, López-López J.
segments13. Osteomyelitis of the jaw (with pathological
Mandibular fractures and osteomyelitis are fracture) following extraction of an impacted
considered rare complications during third molar wisdom tooth. A case report. J Stomatol Oral
removal surgery14. However, it is necessary to Maxi. 2017;118(5):306-9.
12. Coviello V, Stevens MR. Contemporary
consider that late fractures may cause
concepts in the treatment of chronic
osteomyelitis, and that early and appropriate
osteomyelitis. Oral Maxillofac Surg Clin North
treatment is important to prevent pathological
Am. 2007;19:523-34.
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CONCLUSION Rohrich RJ. Does hyperbaric oxygen therapy
Although jaw fractures due to work in facilitating acute wound healing: a
osteomyelitis are rare, it is important to prevent systematic review. Plast Reconstr Surg.
them. In this case, the 2.4 plate reconstruction 2014;133(2):208-15.
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calcitonin in the treatment of chronic
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osteomyelitis of the mandible: case report. Br J
helped the patient's health recovery.
Oral Maxillofac Surg. 2008;46:400-402.
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