A narrative review of atrophic mandible fracture management

Introduction

Background

Atrophy of the mandible is a physiologic process associated with both normal aging and loss of dentition. The purpose of the alveolar bone segment is to support and house teeth; once there is loss of dentition, the occlusal forces and load that stimulates the alveolus is also lost, leading to resorption, loss of bone volume, and resultant thinning of the mandible (1). Weight-bearing physical activity (mastication) is necessary to build and maintain bone density, which once lost leads to atrophy (2). Edentulous mandibles, with their low bone density and volume, are thus prone to fracture (3).

The population of the United States over the age of 65 reached 16.8% per the 2020 census, the largest proportion it has ever been in the history of the nation (4). While the overall prevalence of edentulism in the United States has decreased in the last decade, presumably due to increased access to dental care, 13.5% of the population reported being completely edentulous in 2020 (5,6). This is still a significant proportion of the population with a wide local distribution within the country: for example, in West Virginia, over 22% of adults over age 65 reported complete edentulism (7). Factors strongly associated with edentulism include low socioeconomic status, having less than a high school education, smoking, and comorbid conditions including diabetes, hypertension, and vascular disease (5).

Atrophic mandible fractures are comparatively rare, with reported incidences between 1–5% of all mandible fractures (8). Luhr in 1996 developed a classification for the edentulous mandible, ranging from class I to III in increasing severity (9). The atrophic mandible is defined as having a vertical height <20 mm. Luhr further classified them as follows: class I has a mandibular bone height between 16–20 mm, class II with 11–15 mm, and class III with 10 mm or less (9).

Rationale and knowledge gap

Despite their relative rarity, fractures of the atrophic mandible present unique challenges to the oral and maxillofacial surgeon. Treatment of these fractures is complicated by diminished blood supply to the mandible, poor bone quality, lack of adequate contact area post-reduction to facilitate union, and a largely elderly patient population with often many comorbid conditions that diminish healing capacity and may pose a relative contraindication for general anesthesia (10-13). Treatment modalities of the edentulous mandible have undergone significant change over the last few decades (14). The primary challenge in the treatment of atrophic mandibles lies in finding a balance between adequately reducing and treating a fracture with poor blood supply, poor bone healing, and minimal fracture contact, while also managing the surgical and medical complexities of the elderly patient (15).

A gap exists in the current literature regarding high-quality evidence to guide these treatment decisions. Most existing studies consist of retrospective case series with small sample sizes, varied treatment protocols, and low statistical power (9,16,17). Several systematic literature reviews exist and have effectively synthesized modern clinical outcome data to validate the success of open reduction and fixation with locking reconstruction plates; however, they are similarly limited to reporting statistical trends from heterogeneous retrospective studies (15-18). Debates regarding the disruption of periosteal blood supply have long complicated the consensus on open versus closed management. As the management of these fractures continues to evolve with advances in technology, there remains a need to synthesize historical lessons and rationale with modern standards to address persistent controversies.

Objective

This review aims to summarize both historical and modern perspectives on the treatment of atrophic mandible fractures, while contextualizing the difficulties of managing such fractures and discussing the settings in which each treatment modality is useful. This narrative review differentiates itself by providing a critical qualitative synthesis of the evolution of care standards. Beyond simply reporting outcomes, we aim to deconstruct the historical pathophysiological debates that long delayed the adoption of modern fixation techniques. We present this article in accordance with the Narrative Review reporting checklist (available at https://fomm.amegroups.com/article/view/10.21037/fomm-25-28/rc).

Methods

A literature search was conducted to identify relevant studies regarding the management of atrophic mandible fractures. Electronic databases including PubMed, Scopus, and Google Scholar were queried to retrieve peer-reviewed articles published in English from inception through September 2025. The search strategy prioritized studies focusing on historical treatment modalities (various methods of closed reduction) and modern surgical techniques along with literature on the pathophysiology of mandibular atrophy and fracture healing. Given the narrative nature of this review, a strict systematic screening protocol was not employed. Instead, articles were selected based on their relevance to the evolutionary narrative of treatment standards, specifically seeking to contrast biological arguments for various treatment methods with clinical outcome data. Key search terms included “atrophic mandible fracture”, “edentulous mandible”, “open treatment”, “closed treatment”, among others. Reference lists of retrieved articles were also manually screened to identify seminal historical papers. After the titles were vetted for relevancy, a full-text review was conducted of selected articles. Specific details of the search strategy are summarized in Table 1.

Discussion

Closed treatment

Minimally invasive closed reduction, potentially under local anesthesia, would seem a logical choice for treatment of a fracture of an elderly patient. However, traditional methods of closed reduction that rely on tooth-bearing segments cannot be utilized in an atrophic mandible without teeth, so closed treatment modalities have drawn from historical methods of fracture treatment such as circummandibular wiring or “Gunning splints” (12,14,15,19). In 1866, Thomas Gunning developed a splint to treat fractures of the edentulous mandible: it was composed of a single rigid segment with a central space for eating that was adapted to the upper and lower ridges of the dental arch. The splint was fixated to both arches with screws. A modified version of this including a variant where the patient’s own dentures were circumferentially wired to the jaws was widely used as the preferred closed treatment for most of the 20^th century, prior to the increased availability and popularity of open treatment (14,19,20). External fixation with pins is another closed treatment method, however it has had limited popularity or practical use due to low bone stock in which to fixate pins and thus poor stability and outcomes (14,18).

Another method of closed treatment is the interrami intraoral Kirshner wire fixation (IRIF) technique which utilizes circummandibular wiring to a horseshoe-shaped K-wire that is attached to each ramus. This technique is described by Shuker as an alternative to the traditional Gunning splint as part of a case study on two patients with atrophic mandible fractures, however limited other literature exists about the use of this technique (21).

Advantages of closed treatment include minimizing or avoiding entirely the use of general anesthesia in patients who are high-risk for surgery and their relatively easy application (19). Additionally, lack of dissection of periosteal tissues maintains some blood supply to the mandible (19). However, the rates of reported complications of closed treatment are high with major concerns for malunion, nonunion, and infection: studies have reported up to a 25% rate of fibrous union in cases of atrophic mandible fractures treated with closed reduction, and a 12.5% rate across all treatment modalities (22-24). This number is significantly higher than the incidence of nonunion across all types of mandibular fracture of <4.5% (25), supporting the difficulty of treating this subset of fractures. This high failure rate is likely due to the inadequate fixation achieved by methods of closed reduction, as muscles and soft tissue pull can prevent adequate seating of dentures and prevent reduction of the already small bony contact area of atrophic mandibles, and do not provide rigid-enough fixation to promote proper fracture healing (23,24).

Open treatment

Open reduction and internal fixation (ORIF) with plates and screws remains the most widely utilized and accepted treatment modality in the modern era (3,24,26). Osteosynthesis plates were first used in mandibular fracture reduction by Sir William Lane in 1895, but significant progress toward their use was not made until the 1960s when Luhr developed plates and screws and initiated large-scale production and the use of antibiotics became prevalent (14). Further development was made in the 1970s by Champy, and into the 1990s and 2000s by Ellis (26,27). In the last decade, there have been incredible advances in open plating technology including better imaging leading to custom titanium plates and screws for open reduction, and advances in anesthetic management that have allowed elderly patients to more safely undergo surgery (12,13,18,24).

Advantages of open reduction include clear visualization of the fracture segments to achieve ideal anatomical reduction and the ability to apply rigid internal fixation allowing for a high degree of stability (28). In atrophic mandibles, the fractured segments are often so small that achieving adequate bone-to-bone contact via closed reduction is very difficult (24). Disadvantages include significantly longer surgical time under general anesthesia, increased technical difficulty for the surgeon, and a more invasive surgery (19). Overall, literature by Luhr, Ellis, and countless others supports the use of ORIF as the primary technique for atrophic mandible fracture management (3,9,11,16,17,23,26).

Blood supply

One of the main points of contention regarding the choice of open versus closed reduction has been the disruption of blood supply of the edentulous mandible. Histological studies by both Bradley and McGregor showed the decreased caliber and contribution of the inferior alveolar artery that occurs over time (29,30). Bradley hypothesized that with aging the major blood supply to the mandible becomes the subperiosteal plexus, elevation of which during surgery may seriously impair the vascular supply to the bone, potentially preventing healing. This thought process, along with the lack of readily available reconstruction plates to support open reduction, was a primary driver of closed treatment in the 1970s and 80s (18,19).

The Arbeitsgemeinschaft fur Osteosynthesefragen (AO) has outlined four fundamental principles for optimal fracture healing: reduction to restore anatomy, stable fixation, maintaining adequate blood supply, and restoration of function through early mobilization (31,32). While all are important factors, multiple studies in orthopedic literature have shown that rigid stabilization of a fracture is a more consequential predictor of healing than blood supply, and fracture healing can occur predictably even in settings of severely diminished blood flow (26). Thus, insufficient reduction or fixation solely to avoid disruption of the blood supply provided by periosteal attachment is not an acceptable justification for closed reduction.

A minor point of discussion occurred in the 1970s–80s regarding performing a traditional subperiosteal dissection or a supraperiosteal dissection when exposing the fracture prior to plating in an open reduction (26,33). The reasoning advocated by some was that a supraperiosteal dissection would preserve some tenuous blood supply to the mandible, however some careful analysis can clearly illustrate that this is a fallacy: periosteum receives blood from the surrounding tissues, so if these are dissected off, then there is functionally no difference in blood supply to the mandible than a subperiosteal approach (26). Additionally, tightly adapting and engaging a reconstruction plate on top of a layer of periosteum with locking screws essentially obliterates the space between the plate and bone, crushing the soft tissue meant to provide blood flow (33). Furthermore, without subperiosteal loosening, visualization and reduction of the fracture segments is impaired (33). Rucker showed that supraperiosteal dissection did not increase blood flow in the maxilla of rabbits (34). Thus, there is no indication to perform a technically challenging supraperiosteal dissection, and standard subperiosteal exposure of fracture segments should be performed (26,33). The surgeon may take care to not detach more periosteum than strictly necessary; for example, to maintain the lingual periosteal attachment while exposing the inferior border of a fracture (16).

Surgical approach

Once a surgeon decides to pursue open reduction, the next question becomes that of the approach. There has been some discourse in the literature regarding the merit of an intraoral or extraoral approach, however there is no clear data from any study supporting the use of one method or the other (17,18,26). The advantages of intraoral approaches are the lack of visible scar and avoidance of the facial nerve and vessels (28). Disadvantages include the theoretical increased risk of infection due to access from a contaminated site versus the clean neck, the presence of the inferior alveolar nerve at/near the crest of the atrophic mandible, and technical challenges of retraction and intra-operative fracture visualization without tooth-bearing segments to help orient and stabilize retractors (16,26,28,33). While some surgeons report success with intraoral approaches (15,17,35), a larger proportion seem to favor the extraoral approach which also allows freedom from oral flora contamination, excellent fracture exposure, and seating of a large load-bearing reconstruction plate (15,16,26,36).

Choice of hardware

The choice of hardware for internal fixation has generally been between load-bearing reconstruction plates versus miniplates. Advocates of miniplates touted the minimal dissection needed to place them and suggested using multiple or longer miniplates to increase stability (35,37), however plate fractures are common likely due to fatigue failure from cyclic loading (22,26,38). Multiple miniplates can help counter this, however atrophic mandibles often do not have sufficient bone height to support this (33). Thus, AO and most modern scholars advocate for larger reconstruction plates, specifically load-bearing plates as the atrophic mandible has insufficient bone stock to share any masticatory load (26,32,33,36). Plate systems of 2.7 mm, 2.4 mm, and most recently 2.0 mm are among the most popular options, especially utilizing locking screw mechanisms (3,24,26). The advantage of locking screws is increased stability across the fracture and that the plate can engage the mandible without being perfectly adapted (26). The AO currently recommends a 2.4 mm locking reconstruction plate with at least 3 screws on either side of the fracture (3). Recently, the 2.0 mm locking reconstruction plate system has become a popular choice due to its low profile, choice in multiple screw lengths, and ability to plate both the lateral and inferior border of the mandible (16,33). Lower profile and inferior border plates are preferred to minimize dehiscence of intraoral soft tissue over protrusive plates and can minimize interference with dental prosthetics (11,16). With the advent and now widespread use of virtual surgical planning (VSP), custom three-dimensional (3D)-printed titanium reconstruction plates can be fabricated for the patient which both reduces operating time and allows for a more perfect anatomic reduction (39,40). Custom materials can be fabricated from both in-office cone beam computed tomography (CT) images or medical-grade scans, and some manufacturers (e.g., Synthes) can have turnaround times of as fast as 3–5 business days. VSP can be used to design a plate and place screws in the optimal position, provide 3D printed models or cutting guides, and is an important tool for the modern surgeon (40). Figures 1-6 illustrate a case of an atrophic mandible fracture that was first treated with closed reduction, then retreated with open reduction and fixation with a VSP inferior border plate.

Figure 1 Panoramic image of a 68-year-old female patient with history of head and neck cancer treated with radiation therapy who sustained a bilateral mandible fracture in a mechanical fall. She was initially treated with closed reduction via circummandibular wiring of her denture, but presented with left-sided pain and swelling on the third post-operative week. The image displays poor reduction of the left segment. Patient images are without any identifiers and used with permission.

Figure 2 Reconstructed images from the patient’s CT scan during the VSP session, from (A) frontal and (B) sagittal views. CT, computed tomography; VSP, virtual surgical planning. Patient images are without any identifiers and used with permission.

Figure 3 Inferior border plate design, from (A) axial (inferior) and (B) frontal (posterior) views. Patient images are without any identifiers and used with permission.

Figure 4 Extraoral approach and exposure of bilateral fractured segments (left, A; right, B) with minimal soft-tissue dissection. Patient images are without any identifiers and used with permission.

Figure 5 Application of custom 3D printed titanium 2.0 mm reconstruction plate. 3D, three-dimensional. Patient images are without any identifiers and used with permission.

Figure 6 Panoramic film from post-operative week 4. The patient is healing well, and has no intraoral dehiscence, no pain or swelling, is tolerating a soft diet, and has appropriate healing of her extraoral incision. Patient images are without any identifiers and used with permission.

Bone grafting

A final point to consider is that of simultaneous bone grafting. Historically, grafts were used to help bridge gaps in segmented mandible fractures or used as a fixation device during reduction of the fracture (26,41). Doing so provided fractures with fixation and, in theory, promoted healing by providing osteocompetent cells to the fracture site. Another reason for grafting could include simultaneous augmentation of the mandible for future prosthetic rehabilitation (24,28,42). Arguments against bone grafting include donor site morbidity in an elderly patient, increased surgical time, and potential increased rates of infection (24). With the widespread availability of reconstruction plates for rigid fixation, bone grafting no longer plays a role in stability of the fixation (26). Studies have shown excellent results with ORIF both with and without simultaneous bone grafting (9,26). Thus, bone grafting during the treatment of atrophic mandibles is an option for cases with continuity defects or with hopes of future prosthetic rehabilitation, though not necessary. A summary of the comparison of the reviewed treatment modalities is found below in Table 2.

Future perspectives and challenges

The management of edentulous mandible fractures continues to evolve with advances in technology and changing treatment philosophies. As life expectancy and the elderly population proportion increases, surgeons will encounter more atrophic mandible fractures despite declining edentulism rates (8). This same demographic shift is driving innovations in geriatric anesthesia and perioperative care, expanding the pool of elderly patients who can safely tolerate operative intervention (13). VSP and patient-specific implants represent a significant technological advancement: while still limited by cost and turnaround time, increasing adoption by surgeons and competition among manufacturers has improved accessibility significantly. The integration of artificial intelligence into VSP workflows could further streamline the design process, automatically suggesting optimal plate contours and screw trajectories based on CT imaging. 3D printing technology may eventually enable intraoperative or even chairside fabrication of custom hardware, though regulatory and quality control challenges must first be addressed (43).

Biomaterial development or use of biologics also offers promise for improving outcomes in atrophic bone. Improved titanium alloys with various surface modifications to promote osteogenesis are areas of active research (44,45). Bone grafting techniques continue to evolve, with growth factors, bone morphogenetic proteins, and scaffold materials potentially enhancing fracture healing without the morbidity of autogenous harvest. Similarly, the potential of platelet-rich plasma or other autologous biologics to augment healing in the poorly vascularized atrophic mandible remains largely unexplored (46).

A significant challenge lies in the paucity of high-quality evidence guiding treatment decisions. Most existing literature consists of retrospective case series with small sample sizes and heterogeneous treatment protocols (9,16,17). The relative rarity of atrophic mandible fractures makes prospective randomized trials difficult, but multi-institutional collaborations and registry-based studies could provide more robust data on optimal hardware selection, surgical approach, and patient selection criteria. Standardized outcome measures beyond simple union rates, including return to oral diet, quality of life, prosthetic rehabilitation, and patient satisfaction, could better characterize the true impact of different treatment approaches. Longer-term follow-up is needed to understand late complications and functional outcomes. As the field progresses, the development of robust evidence through collaborative research efforts will be critical to translating technological advances into meaningful improvements in patient care.

Limitations

As this is a review paper, limitations include the lack of novel data presented, and the heterogeneity and low power of existing studies referenced. Additionally, the majority of fractures in the reviewed literature are of the angle, body, or (para)symphysis of the atrophic mandible. Condylar or subcondylar fractures of the atrophic mandible are significantly rarer (47) and there is a paucity of literature on this topic. Thus, this narrative review does not adequately capture treatment of this subset of atrophic mandible fractures.

Conclusions

In summary, our literature review reveals that ORIF through an extraoral approach, using a standard subperiosteal dissection and rigid fixation with load-bearing plates of minimum 2.0 mm thickness is a surgical plan for treatment of atrophic mandible fractures that predictably yields good results for the patient. The surgeon should be mindful to minimize unnecessary dissection of soft tissues during the operation to preserve centripetal blood flow to the mandible, but the advantage of adequate reduction with rigid fixation is greater than the disadvantage of potential disruption of blood flow from periosteal dissection. Single load-bearing reconstruction plates with a minimum size of 2.0 mm appear to yield the best results. The surgeon may consider bone grafting at the time of reduction, but the benefits of this may solely be limited to augmentation of the mandible for future prosthetic rehabilitation as no clear advantages of grafting for fracture union have been shown in the literature. Closed reduction has generally fallen out of favor due to the lack of reliable and adequate 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 geriatric population. The treatment of this difficult subset of fractures is complicated, both technically and due to the complexities of the elderly patient. Treatment should be tailored to the patient’s individual needs. While other treatment modalities exist, intervention with open reduction and rigid internal fixation via an extraoral approach should be considered the standard of care.

Acknowledgments

Thank you to Dr. Rabie Shanti, DMD, MD, for allowing the use of his clinical photos and to Dr. Vincent B. Ziccardi, DDS, MD, for supporting our participation in this review.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://fomm.amegroups.com/article/view/10.21037/fomm-25-28/rc

Peer Review File: Available at https://fomm.amegroups.com/article/view/10.21037/fomm-25-28/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://fomm.amegroups.com/article/view/10.21037/fomm-25-28/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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