Here's an interesting case from this year. It highlights one of the consequences of full mouth extraction in women at an early age.

This is an 84 y/o physically and cognitively active retired nurse who had a couple syncopal episodes this winter, and fell on her mandible. After having a pacemaker placed for her sick sinus syndrome, she continued to have left mandibular pain while chewing. This prompted a CT several weeks later that showed a fracture, and she was referred to me. She was completely edentulous, and her mandibular denture had been lost by the hospital. Her panoramic radiograph shows a moderately displaced fracture of the left body of the mandible. The other remarkable part of her medical history is that she had orthognathic surgery of the mandible more than 30 years ago, and there are osteosynthesis wires bilaterally at the angles of the mandible.

[image:1_DM_pre_op_panorex.jpg]

She had no intraoral wounds, and she had no lip paresthesia. There was only modest mobility of the segments. This fracture was behaving as a fibrous union because of the nearly 6 weeks since the fall and the way the ends of the fracture could not be moved much. I explained that if she was debilitated or did not normally chew her food (for example if she had a feeding tube), then it would be okay to not operate on this, because it would probably remain this way indefinitely. She was a spirited, active octagenarian, so wanted to go back to chewing without pain.

The standard of care to repair this type of atrophic edentulous mandible fracture is to place a load-bearing reconstruction plate. This requires a fairly generous submandibular incision, which can place the facial nerve at hazard. The fibrous union must be separated and the ends of the fracture "freshened". This is a fracture that has a high complication rate because of the small bone-to-bone contact area, and the age-related reduction of our healing capacity. There is typically no way to avoid injuring the IAN with the screws and the manipulation of the fracture. She was willing to accept the expected lip anesthesia, and was appraised of the risk of possible facial nerve (lower lip/chin) weakness. I also explained that sometimes the bone plate will interfere with wearing a new denture, and that sometimes the bone plate will need to be removed in the future. This type of procedure realistically requires 4-6 six hands to complete the surgery. I'm fortunate fo be able to work with the OMS residents in Indianapolis for these kinds of cases.

Here is an intra-operative photo of the fracture reduction, and an immediate post-op radiograph.

[image:2_DM_intra_op_reduction.jpg]

[image:3_DM_post_op_panorex.jpg]

She was kept on a pureed consistency diet for over 6 weeks, and did well. Here is her panoramic x-ray at that point, and her neck incision.

[image:Final_panorex.jpg]

[image:Post_op_incision.jpg]

The good news was that I was not able to palpate the top of the plate in the buccal vestibule, nor any of the screw ends on the lingual side. I told her that it would be okay to proceed with getting new dentures made, and asked her dentist to be careful about the flanges in this area. Also, she did have some partial lip sensation, which was a great surprise. She says the paresthesia didn't bother her, but she always puts a positive spin on anything she says! Unfortunately she had more lip weakness than I would have liked to see. I will say that it often takes 3-6 months for it to come back. This is typically from inadvertent traction on the marginal mandibular branch of the facial nerve. We use an intraoperative nerve stimulator to help identify it during the dissection, and then retract it out of the field. Here is what her lip looked like.

[image:Post_op_lip_asymetry.jpg]