A pathological fracture of the mandible due to osteomyelitis following a full dental clearance

A 58-year-old female patient presented at an oral and maxillofacial outpatient clinic with a nine-month history of pain, swelling and draining fistulas at the right angle of mandible and submental region. This was following a staged full dental clearance by her general dental practitioner. A 10-week course of oral antibiotics had already been prescribed without resolution of symptoms or signs. On presentation she was afebrile with a normal pulse rate and blood pressure. She had a swollen right face, trismus and suppurative infection draining from these fistulas (Figure 1); there was no palpable lymphadenopathy. Intra-orally there were draining fistulas present on the alveolar mucosa of the right body of the mandible and mobility of the mandible was present at the right angle and symphysis. Radiographic examination was carried out with an OPT but, due to patient factors, a diagnostic image was unachievable and CT imaging was undertaken. This revealed gross destruction of the right ramus and symphysis of the mandible, associated pathological fractures and multiple sequestrae with pockets of gas in the soft tissues in keeping with infection. The coronoid and condylar processes, as well as the proximal body of mandible, were noted to be markedly sclerotic on the right-hand side with a lamellar type periosteal reaction. These features were felt to be consistent with a diagnosis of chronic suppurative osteomyelitis (Figures 2–5). A white cell count, CRP and bone profile were normal.