Management of atrophic mandibular fracture in an elderly patient on long-term bisphosphonate therapy: a case report

Atrophic mandibular fractures in elderly patients on long-term bisphosphonate therapy pose a clinical challenge due to compromised bone quality and healing capacity. These cases carry a heightened risk of complications, including bisphosphonate-related osteonecrosis of the jaw. This report presents the successful surgical management of such a fracture in an elderly female patient. A 73-year-old edentulous woman presented with a left mandibular body fracture following a ground-level fall. Her medical history included osteoporosis treated with alendronate for five years, hypertension, and type II diabetes. Clinical and imaging assessments confirmed an atrophic mandibular fracture. Following medical optimization, including alendronate discontinuation and glycemic control, the patient underwent open reduction and internal fixation (ORIF) via a left submandibular approach using a 2.3 mm locking titanium plate. Postoperative care included intravenous antibiotics, analgesics, dietary adjustments, physiotherapy, and oral hygiene measures. The PENTO protocol (Pentoxifylline and Tocopherol) was administered to reduce the risk of osteonecrosis. The patient’s recovery was uneventful, with progressive improvement of mild paresthesia and no signs of infection or osteonecrosis over eight months of follow-up. This case demonstrates that surgical management of atrophic mandibular fractures in bisphosphonate users can be performed safely with proper preoperative planning, drug management, and use of prophylactic pharmacologic strategies. Load-bearing fixation and extraoral access optimized fracture stability while reducing the risk of infection. Open surgical treatment with internal fixation, combined with careful perioperative management and the PENTO protocol, demonstrated as an effective approach for managing atrophic mandibular fractures in elderly patients on bisphosphonate therapy.