Conservative Management of Severe Medication-Related Osteonecrosis of the Jaw With Pathological Fracture

Medication-related osteonecrosis of the jaw (MRONJ) is a well-known risk following dental extraction in patients taking certain medications. Pathological fracture secondary to MRONJ often requires complex operative intervention. This case demonstrates the conservative management of pathological fracture secondary to MRONJ in a patient with multiple comorbidities. The patient developed MRONJ with pathological fracture following extraction of the mandibular second molar. The patient presented with significant surgical risk factors, having hypertension and a recent stroke, causing dense left hemiparesis, subsequently resulting in transition to high-level nursing care. Given the high risk of reconstructive surgery, nonoperative management was undertaken. Following a course of long-term antibiotics with resolution of signs of infection, the case was managed conservatively with chlorhexidine-based mouthwash and soft diet. With routine clinico-radiographic assessment and optimal oral health care, the pathological fracture did not require operative intervention. Healing progressed well with no clinical complications and radiographic evidence of good healing at 6- and 12-month follow-up on orthopantomogram. A role for conservative management of pathological fractures secondary to MRONJ yet exists, especially in the elderly population. This case highlights the importance of developing treatment plans based on individual patient context and clinical assessment.