A narrative review of atrophic mandible fracture management

Background and Objective: Management of fractures of the atrophic mandible is a topic that has challenged oral and maxillofacial surgeons for decades. Treatment of these injuries presents unique difficulties due to decreased bone volume, compromised vascularity, and medical complexity of the elderly patient population that can lead to a high rate of failure and complications. While recent systematic reviews have effectively synthesized clinical outcome data to validate the success of locking reconstruction plates, such reviews are often limited to reporting statistical trends from heterogeneous retrospective studies. This narrative review aims to summarize both historical and modern perspectives on management, contextualize them, and provide practical guidance on best practices and standards of care.

Methods: A literature search was conducted utilizing databases including Google Scholar, Scopus, and PubMed. The search focused on peer-reviewed articles published in English covering the period from inception to September 2025. Relevant studies and case reports regarding historical treatment modalities and modern surgical techniques were selected, compiled, and summarized.

Key Content and Findings: Historical closed reduction methods are associated with high rates of nonunion rates due to muscle pull and inadequate fixation and bony contact, though their theoretical advantages include being minimally invasive and preserving blood supply. Evidence indicates that rigid stabilization is a more significant predictor of healing than periosteal preservation, thus open reduction and internal fixation (ORIF) has emerged as the standard of care. Current consensus favors an extraoral approach utilizing load-bearing reconstruction plates, specifically locking systems of at least 2.0 mm thickness, to ensure stability. While bone grafting during repair remains an option for future prosthetic rehabilitation, it is not required for fracture union.

Conclusions: While treatment must be tailored to the individual, open reduction via an extraoral approach with rigid internal fixation should be considered the standard of care for atrophic mandible fractures. Closed reduction has largely fallen out of favor due to unreliable healing, and improvements in technology for both custom reconstruction plate manufacturing and general anesthesia have allowed for open reduction to proceed safely and predictably in the elderly population.