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Review
. 2021 Dec 23;15(1):608.
doi: 10.1186/s13256-021-03206-5.

An unusual case of bone regeneration of a necrotic mandible with pathologic fracture in an elderly hemodialysis patient with medication-related osteonecrosis of the jaw: a case report and review of the literature

Kunio Yoshizawa  1 , Akinori Moroi  2 , Ran Iguchi  2 , Akihiro Takayama  2 , Junko Goto  3 , Yutaka Takayama  4 , Koichiro Ueki  2
Affiliations
Review

An unusual case of bone regeneration of a necrotic mandible with pathologic fracture in an elderly hemodialysis patient with medication-related osteonecrosis of the jaw: a case report and review of the literature

Kunio Yoshizawa et al. J Med Case Rep. .

Abstract

Background: Bisphosphonates are frequently used for osteoporosis. Medication-related osteonecrosis of the jaw, a complication of bone-modifying agents, including bisphosphonates or angiogenic inhibitors, can be challenging to treat in elderly patients with numerous preexisting conditions. Achieving good treatment outcomes is especially difficult in patients with pathological fractures accompanied with extraoral fistulae.

Case presentation: We report an unusual case of prominent bone regeneration following palliative surgical treatment in a 72-year-old Japanese female patient undergoing hemodialysis. She previously had severe osteoporosis due to renal osteodystrophy and was receiving antiresorptive intravenous bisphosphonate. Computed tomography revealed a discontinuous left lower mandibular margin with a pathologic fracture and extensive, morphologically irregular sequestrum formation (80 × 35 × 20 mm). The patient was diagnosed with stage III medication-related osteonecrosis of the jaw and pathologic mandibular fracture. Immediately before the surgery, the anticoagulant used for dialysis was changed from heparin to nafamostat mesylate to reduce the risk of intraoperative bleeding. Sequestrectomy was performed under general anesthesia. Postoperative infection was not observed, the intraoral and submandibular fistula disappeared, and, surprisingly, prominent spontaneous bone regeneration was observed postoperatively at 6 months. Despite the severe systemic condition of the patient, the conservative surgical approach with sequestrectomy has yielded desirable results for more than 6 years since the surgery.

Conclusions: This rare report of spontaneous bone regeneration in a patient of advanced age and poor general condition is the oldest case of mandibular regeneration ever reported.

Keywords: Hemodialysis; Medication-related osteonecrosis of the jaw; Regeneration; Sequestrectomy.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Preoperative appearance and imaging results of our patient. a Lower facial appearance showing a chronic inflammatory reaction with a pustular discharge. b Intraoral view showing necrotic bone and mucosa inflammation on the left half of the mandible. c Panoramic radiograph showing a large sequestrum with a fracture of the left mandible. d Computed tomography scan showing sequestrum and fracture in the left mandibular plane
Fig. 2
Fig. 2
The patient’s clinical course leading up to surgery for sequestrectomy. CKD-BMD chronic kidney disease–mineral and bone disorder, IVD intravenous drip, HD hemodialysis, MRONJ medication-related osteonecrosis of the jaw, YAM young adult mean. “20XX” indicates the year when the patient was first referred to our department
Fig. 3
Fig. 3
Appearance and imaging results of our patient 3 years after surgery. a Lower facial appearance showing with no inflammatory reaction or fistula. b Intraoral view showing no exposed bone. c Panoramic radiography showing regenerated bone of continuous thickness in the left mandible. d Three-dimensional computed tomography showing the preserved mandibular foramen and thick, continuous bone
See this image and copyright information in PMC

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