Images in Clinical Rheumatology
Bilateral pathologic mandibular fracture in maxillary osteonecrosis induced by bisphosphonates
Fractura patológica mandibular bilateral en osteonecrosis maxilar inducida por bisfosfonatos
Jose Darío Sánchez López
, Paolo Cariati, Miguel Angel Perez de Perveval Tara
Corresponding author
Servicio de Cirugía Oral y Maxilofacial, Complejo Hospitalario Universitario de Granada, Granada, Spain
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On suspicion of the cancer spreading to the bone, treatment with zoledronic acid (Zometa®), an intravenous biphosphonate was initiated, at a dose of 4<span class="elsevierStyleHsp" style=""></span>mg/3 months until 2014.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In 2015, with no other precipitating factors (for example oral surgery), active intraoral discharge was clinically detected and exposure of the intraoral necrotic bone. Panoramic radiograph was performed which showed bilateral mandibular non displaced fracture (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). At the moment, following antibiotic treatment with amoxicillin 1<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h and daily mouth rinses every 8<span class="elsevierStyleHsp" style=""></span>h with 2% chlorhexidine, clinical evolution has been stable, without any fragment displacement that requires surgery.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">There are many mechanisms of action of biphosphonates, including: reduction of bone reabsorption due to the inhibition of the osteclastic activity, induction of apoptosis of osteoclasts, antiangiogenic action and alteration of physiological bone remodelling.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> These actions on the bone lead to fragility and incapacity for repairing microfractures due to repetitive stress which, associated with terminal irrigation of the lower jaw, turns this area into a region which is liable to suffer osteonecrosis and in exceptional cases, pathological fractures.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There are currently 4 stages to classify mandibular osteonecrosis according to the regulations established by the American Association of Oral and Maxillofacial Surgeons,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> with our case presented here corresponding to stage four. The case presented appears to prove that individual patient factors, combined with the characteristics of the biphosphonate used (zoledronic acid), the intravenous administration and prolonged administration, as well as its high potency,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5,6</span></a> were the predisposing factors for the appearance of massive osteonecrosis of the jaw.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-10-17" "fechaAceptado" => "2018-01-09" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sánchez López JD, Cariati P, Perez de Perveval Tara MA. Fractura patológica mandibular bilateral en osteonecrosis maxilar inducida por bisfosfonatos. Reumatol Clin. 2020;16:62–63.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 624 "Ancho" => 1300 "Tamanyo" => 72931 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Image showing the bilateral fracture of the jaw in a mandibular osteonecrosis induced by biphosphonate (the 2 arrows mark the fracture lines).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of adjuvant bisphosphonates and other bone-modifying agents in breast cancer: a Cancer Care Ontario and American Society of Clinical Oncology clinical practice guideline" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. 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| 2023 June | 46 | 21 | 67 |
| 2023 May | 47 | 23 | 70 |
| 2023 April | 37 | 7 | 44 |
| 2023 March | 49 | 25 | 74 |
| 2023 February | 51 | 24 | 75 |
| 2023 January | 41 | 7 | 48 |
| 2022 December | 56 | 22 | 78 |
| 2022 November | 56 | 26 | 82 |
| 2022 October | 54 | 29 | 83 |
| 2022 September | 51 | 24 | 75 |
| 2022 August | 33 | 38 | 71 |
| 2022 July | 37 | 31 | 68 |
| 2022 June | 36 | 25 | 61 |
| 2022 May | 38 | 40 | 78 |
| 2022 April | 35 | 33 | 68 |
| 2022 March | 28 | 36 | 64 |
| 2022 February | 46 | 26 | 72 |
| 2022 January | 57 | 33 | 90 |
| 2021 December | 32 | 41 | 73 |
| 2021 November | 27 | 45 | 72 |
| 2021 October | 43 | 48 | 91 |
| 2021 September | 30 | 42 | 72 |
| 2021 August | 25 | 47 | 72 |
| 2021 July | 25 | 32 | 57 |
| 2021 June | 21 | 38 | 59 |
| 2021 May | 37 | 53 | 90 |
| 2021 April | 70 | 102 | 172 |
| 2021 March | 76 | 38 | 114 |
| 2021 February | 36 | 14 | 50 |
| 2021 January | 45 | 25 | 70 |
| 2020 December | 42 | 17 | 59 |
| 2020 November | 23 | 15 | 38 |
| 2020 October | 32 | 21 | 53 |
| 2020 September | 39 | 23 | 62 |
| 2020 August | 19 | 13 | 32 |
| 2020 July | 27 | 14 | 41 |
| 2020 May | 1 | 0 | 1 |
| 2020 January | 1 | 0 | 1 |
Show all
