Int. J. Oral Maxillofac. Surg.

2013; 42: 611–614

http://dx.doi.org/10.1016/j.ijom.2013.02.004, available online at http://www.sciencedirect.com

Case Report
Clinical Pathology

Extra-platysma fixation of F. Biglioli, M. Pedrazzoli

Department of Maxillofacial Surgery, San
Paolo Hospital, University of Milan, Milan, Italy

bisphosphonate-related
mandibular fractures: a
suggested technical solution
F. Biglioli, M. Pedrazzoli: Extra-platysma fixation of bisphosphonate-related
mandibular fractures: a suggested technical solution. Int. J. Oral Maxillofac. Surg.
2013; 42: 611–614. # 2013 International Association of Oral and Maxillofacial
Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is an evolving

epidemic. Often the patients are in poor general condition and therefore the aim of
surgical treatment is generally limited to pain control and restoration of feeding
ability. We present a useful surgical technique for the stabilization of BRONJ-
related mandibular fractures, including application of a reconstructive plate. With
an extraoral approach, a 2.5-mm reconstructive locking plate is contoured and
placed in the plane of dissection, superficial to the platysma. The fracture site is
accessed through an intraoral approach, which limits surgery to curettage and
rinsing of the surgical site. Since there is no removal of the periosteal support to the
residual stumps, the blood supply to the affected mandible is maintained. Avoidance
of direct contact of the infected fractured site with the reconstructive plate is another
advantage of working in a surgical plane over the platysma muscle. Although
fracture healing is not achieved, plate fixation with this technique is stable and
painless and patients can easily eat; therefore, patients enjoy a great improvement in
their quality of life. We consider this easy and effective procedure to be a reliable Accepted for publication 11 February 2013
palliative solution in these patients. Available online 13 March 2013

Bisphosphonate-related osteonecrosis of
the jaw (BRONJ) is an evolving epidemic
encountered by maxillofacial surgeons.
Since the first report of BRONJ described
by Marx in 2003,1 many new cases have
been described, but the causes of this
disease are still debated. The most widely
accepted etiopathological hypothesis pro-
poses that in certain individuals, bispho-
sphonates increase trabecular bone
density, inducing vascular insufficiency
and causing bone necrosis.2 The devascu-
larized bone is then highly susceptible to
infection.
Most surgeons advise prevention and
conservative symptomatic treatment con-
sisting of the simple removal of the necro-
tic bone.3 At times, further surgical
treatment becomes necessary if infec-
tion-induced pain and inflammation are
not relieved by simple sequestrum
removal. Often, conservative treatments
do not halt disease progression, and the
pathological situation advances to a wor-
sening clinical grade, requiring more com-
plex management. The necrosis can
evolve and produce an extraoral fistula
and osteolysis extending to the inferior
border, which can progress to mandibular
fracture (Fig. 1). In the literature there are

0901-5027/050611 + 04 $36.00/0 # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
612 Biglioli and Pedrazzoli
Fig. 1. Panoramic radiograph revealing wide bone destruction in the anterior region of the
mandible, and a pathological fracture in the right body.
very few reports of the treatment of patho-
logical mandibular fracture caused by
BRONJ.4–6
Often the patients are in poor general
condition and concurrently suffering from
metastatic cancer. Moreover, the long
clinical history of local infection and
chronic antibiotic therapy often leads to
depleted energy reserves. Due to these
conditions, the aim of surgical treatment
in generally limited to pain control and
restoration of feeding ability. There are
reports of segmental resection and direct
sub-periosteal open reduction of the frac-
ture, with or without stabilization using a
reconstruction Plate.6
The circumstances surrounding
BRONJ-related fractures may not be
recommended for traditional open surgery
with direct positioning and plate stabiliza-
tion, due to the high risk of increased
reduction of vascular flow to the bone
stumps. Moreover, the rigid fixation is
Fig. 2. Intraoperative view: the position of the 2.5-mm plate in the extra-platysmatic plane.
likely to fail due to infection in the plates
and screws and the presence of pus in the
surgical field. These conditions impair
fracture healing and maintain infection.
Here, we present a useful surgical tech-
nique for the stabilization of BRONJ-
related mandibular fractures, including
application of an extra-platysma recon-
structive plate, with no contact between
the osteosynthesis material and the
infected mandibular site. Although frac-
ture healing is not achieved, plate fixation
with this technique is stable and painless
and patients can easily eat; therefore,
patients enjoy a great improvement in
their quality of life.
Surgical technique
Five minutes prior to the start of surgery,
1:200,000 epinephrine is injected subcu-
taneously along the mandible and into the
submandibular region. A 10-cm skin inci-
sion is made that is set on a well-defined
submandibular wrinkle a few cm inferior
to the mandibular border. A dissection in a
surgical plane over the platysma muscle is
then performed, 5 cm in the front and 5 cm
in the back, to the fracture site.
Fracture reduction is achieved manu-
ally, without any visual control of the
rim. Further, individual occlusion is
restored and maintained temporarily
solely by hand pressure. No maxillo-man-
dibular fixation is applied in order to avoid
the possible onset of newBRONJ sites.
A 2.5-mm reconstructive locking plate
is modelled and placed in the plane of
surgical dissection, superficial to the pla-
tysma (Fig. 2). Screws are placed a few cm
distant from the palpable bone fracture,
which is not in direct sight of the marginal
mandibular branches of the facial nerve.
Meticulous haemostasis and the appli-
cation of an aesthetic, well-hidden suture
finish the extraoral surgical procedure.
The cervical suture is covered by a dres-
sing, and the fracture site is accessed
through a minimal intraoral approach that
limits surgery to curettage and rinsing of
the surgical site.
Discussion
BRONJ is a clinical situation that is
increasingly observed.1 The effectiveness
of the drugs in preventing bone pain and
resorption in osteoporosis, and in control-
ling bone metastasis in the oncologic
population, has led to the increased use
of this therapy.1 This situation can occur
with both the oral and systemic adminis-
tration of bisphosphonates, the latter being
more risky.7 The cumulative incidence of
BRONJ ranges from 0.8% to 12%, and
these values are increasing over time.7
In their updated guidelines of 2009, The
American Association of Oral and Max-
illofacial Surgeons (AAOMS) provides
guidance to clinicians regarding risk fac-
tors for developing BRONJ and informa-
tion related to the diagnosis and
management of patients with BRONJ.7
In this paper, the AAOMS also proposes
a modified staging system that is used to
more accurately stratify patients, as out-
lined below. The at-risk category includes
asymptomatic patients previously treated
with either oral or intravenous bispho-
sphonates.
! Stage 0: No clinical evidence of necro-
tic bone, but nonspecific clinical find-
ings and symptoms.
! Stage 1: Exposed necrotic bone, asymp-
tomatic, and with no evidence of infec-
tion.
 BRONJ-related mandibular fractures 613

! Stage 2: Exposed and necrotic bone This condition can easily disrupt the long- the limitation of masticatory function in
associated with infection as evidenced term stability of osteosynthesis and main- those who are compromised clinically.
by pain and erythema in the region of tain active infection at the site indefinitely. Secondary reconstructive options can be
exposed bone, with or without purulent In the literature, there are reports considered if the patient’s general condi-
drainage. describing how immediate reconstruction tion is appropriate and the patient requests
! Stage 3: Exposed and necrotic bone in after resection of the mandible affected by this.
patients with pain, infection, and one or BRONJ is possible. Nocini et al.9 reported Applying the well-known concepts of
more of the following: exposed and on a successful vascularized fibula free fracture reduction and stabilization in the
necrotic bone extending beyond the flap reconstruction after mandibular resec- atrophic jaw,10 where care is taken not to
region of alveolar bone, resulting in tion in seven patients, with a mean follow- reduce bone vascularization of the weak
pathologic fracture; extraoral fistula; up period of 23 months. They chose this mandible, we propose an extraoral
oral antral/oral nasal communication; radical treatment for BRONJ since they approach using fracture stabilization in a
and osteolysis extending to the inferior had previously shown that a properly plane superficial to the platysma muscle.
border of the mandible or the sinus planned surgical resection has a high cura- Use of this surgical plane carries no risk of
floor. tive potential in BRONJ patients. They injuries to the facial nerve since the mar-
surmised that in selected patients, this is ginal mandibular branch lies ventrally. A
A simple removal of the exposed a reliable solution to guarantee a long- complete loss of function in the marginal
intraoral bone is advised as a conservative term solution to BRONJ. mandibular nerve is not likely, although,
treatment in the early stages. When Due to the general clinical condition of in theory, temporary partial damage of one
approaching more complex clinical situa- patients with BRONJ-related mandibular branch of the nerve could occur during
tions, as with stage 3 patients who have fractures, it is not feasible to operate on rigid fixation, while holes are drilled for
pathological fractures, the optimum man- patients with such long microsurgical subsequent screws. Since there is no
agement is not currently standardized. reconstructions, as there is a high risk removal of the periosteal support to the
These patients typically have pain that of perioperative complications and free residual stumps, blood support to the
impacts their quality of life. Surgical deb- flap loss. affected mandible is maintained. In addi-
ridement/resection, in combination with Coletti and Ord4 reported on the recon- tion, avoidance of direct contact of the
antibiotic therapy, may offer a long-term struction of the resected mandible with infected fractured site with the reconstruc-
palliative and valid solution. bone grafts, in which the graft itself sur- tive plate is another advantage of working
Aarabi et al. proposed the management vived, but a non-union between the sur- in such a superficial plane.
of a pathological fracture of the mandib- face mandible/bone graft was observed. Occlusion is achieved by direct reduc-
ular angle that includes removal of bone In patients at an advanced stage of tion and maintained by holding the stumps
sequestrum and resectioning until unin- BRONJ with mandibular fracture, the in the correct position. The technique is
volved bone is reached.8 The stumps of more troublesome problems are pain and performed without the use of intermaxillary
the fractured mandible are covered by a
platysma muscle flap without the reestab-
lishment of mandibular continuity. Main-
tenance of the occlusion with an
orthodontic appliance for 12 weeks post-
operatively was suggested. Although this
is a good method for achieving long-term
palliation, no attempts to heal the fracture
are made, and the formation of a simple
rigid scar may not be enough to re-estab-
lish individual occlusion.
Conversely, there are authors who sug-
gest resection with traditional internal
fixation.6 Wongchuensoontorn et al.6 pre-
sented three patients with BRONJ-related
fractures who were treated with mandib-
ular resection and internal rigid fixation
with 2.4-mm locking plates. One patient
died 6 months after the operation; there-
fore, a follow-up was impossible. The
second patient suffered progression of
BRONJ on the resected stumps at 6
months, but also demonstrated stable
osteosynthesis. The third patient showed
stable results at 6 months.
The disadvantages of this simple treat-
ment approach are, in our opinion, expos-
ing the unaffected bone, which reduces the
vascular flow to the mandible, and allow-
ing communication of the infected site of Fig. 3. Postoperative image (at 4 months). Three-dimensional computed tomography scan
the fracture with the reconstructive plate. showing the stable position of the reconstructive plate from a lower view.
614 Biglioli and Pedrazzoli
Fig. 4. Postoperative image (at 4 months). Three-dimensional computed tomography scan
showing the preserved shape of the mandible from a lateral view.
screw fixation to avoid further development
of BRONJ at other sites. To reduce the risk
of further BRONJ formation, screws are
slowly drilled and copious lavage with
rinsing solution is used. The skin incision
is made 2 cm inferior to the mandibular
border, not only for aesthetic purposes, but
also to avoid the decubitus of the recon-
structive plate with its expulsion.
The use of a locking plate is essential in
order to maintain the obtained occlusion
position and to avoid excess pressure on
the platysma muscle and periosteum,
therefore preventing interference with
the blood supply to soft and hard tissues
and injuries to the underlying marginal
mandibular nerve.
The oral approach stage of the operation
is limited to curettage and rinsing of the
surgical site. Plate contamination and the
formation of major abscesses can be pre-
vented by the persistence of an oral expo-
sure or draining fistula.
Rapid relief and preservation of normal
masticatory function is achieved, and the
patient recovers safely and quickly. The
typical discharge time is 2 days post-sur-
gery. The results are stable over time, even
if healing of the fracture is not accom-
plished (Figs 3 and 4). Another advantage
for these compromised patients is the ease
and speed with which this surgical proce-
dure is performed. However, even with
this procedure, BRONJ may be observed
years later, and sequelae such as plate
exposure, infection, and instability, with
subsequent plate removal and mandibular
resection, may occur. We consider this
easy and effective procedure to be a reli-
able palliative solution in these patients.
Therefore, this option is an advancement
in the treatment of this disease.
For BRONJ-related mandibular frac-
tures, we recommend this surgical treat-
ment because it is quick, easy, and
appropriate. In the future, we will provide
follow-up reports on patients who have
undergone this technique to discuss our
findings and impressions.
Funding
None.
Competing interests
None declared.
Ethical approval
Not required.
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Address:
Dr Marco Pedrazzoli
San Paolo Hospital
Via di Rudinı̀ 8
20142 Milan
Italy
Tel: +39 02 81844593; Fax: +39 02 81844704
E-mail: marcomxf@gmail.com