COMPETITIVE STRATEGY MODEL AND ITS IMPACT ON MICRO BUSINESS UNITOF LOCAL DEVELOPMENT BANKSIN JAWA PJAEE, 17 (7) (2020)

AWARENESS ON PATHOLOGICAL FRACTURES AMONG DENTAL STUDENTS – A SURVEY

Nur Liyana Hannah Binti Izham Akmal1, Dhanraj Ganapathy2 1Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai. 2Professor and Head Department of Prosthodontics Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, 162, Poonamallee HighRoad,Chennai 600077,Tamil Nadu, India [email protected],[email protected]

Nur Liyana Hannah Binti Izham Akmal, Dhanraj Ganapathy. AWARENESS ON PATHOLOGICAL FRACTURES AMONG DENTAL STUDENTS – A SURVEY -- Palarch’s Journal Of Archaeology Of Egypt/Egyptology 17(7), 1380-1394. ISSN 1567- 214x

Keywords: Dental; Fracture; Pathologic; Spontaneous

ABSTRACT Pathological fractures may be one of the earliest signs of metastatic disease to the . It may occur due to the underlying pathological process that weakens the bone. Numerous treatment options are available for the management of pathological fractures which may vary according to its multiple etiologies, local bone condition and other serious conditions which may contribute further to its occurrence. This study is done to inform dental practitioners regarding pathological fractures and the importance of proper diagnosis and treatment for patients with such conditions. The aim of this study is to evaluate the awareness of dental students on the various factors associated with pathological fractures and its management. A questionnaire-based study was done involving 100 participants. The inclusion criteria of this study were dental students ranging from third years to post-graduates with personal experiences of working in a dental setting. Questions related to the awareness of pathological fractures were provided. Data was collected and analyzed using the SPSS version 23.0. Pathological fractures are believed to have a low occurrence rate with only 35% of the participants having experienced treating patients with such conditions seen mainly in the mandibular body (51%). Despite this, 55% of them are confident in treating patients with pathological fractures. Most of them are aware of the factors leading to pathological fracture (63%) with osteoradionecrosis being the most common etiology (37%). Most participants are well- informed on the treatment modalities available (60%), having familiarity with the terms “open reduction” and “closed reduction” (61%) while only 58% are aware of the complications associated with them. Closed reduction with intermaxillary fixation/intermaxillary elastic traction is chosen as the ideal treatment of fracture with (84%). Within the limits of our study, it can be concluded that

1380

COMPETITIVE STRATEGY MODEL AND ITS IMPACT ON MICRO BUSINESS UNITOF LOCAL DEVELOPMENT BANKSIN JAWA PJAEE, 17 (7) (2020) awareness about different management of jaw fractures among dental students is moderate and pathological fractures are one of the common factors that lead patients to the dental clinic. It is important for every dentist to have a basic understanding of pathological fracture and its management to provide a proper diagnosis and treatment plan for patients with such conditions.

INTRODUCTION Pathological fracture is a condition which occurs due to weakening of the bone by an underlying pathological process even when being subjected to loading forces within the normal capacity.1234Pathological fracture may affect any bone in the human body, including the orofacial skeleton in which the mandible is the most common location where pathological fractures take place although its occurrence rate is considered low.123In , mandibular fractures is one of the common complaints of dental patients following an injury, accounting for approximately 36% to 59% of all facial fractures.15However, pathological fractures of the mandible are considered uncommon as it contributes to only 1% - 2% of all mandibular fractures.1678 The process of bone weakening may be congenital such as improper development or acquired such as severe alveolar atrophy following long-term edentulism.9

Most cases of pathological fractures are seen in old patients. A study by Abir et al., reveals that most pathological mandibular fractures occur in patients aged 40 years and above which covers about 80% of the total cases in their study.1 It was stated that this condition is influenced by various factors such as atrophic edentulous bone and malignancy seen in elderly patients. 2Various etiologies have been associated with pathological fractures which include the removal of impacted or ectopic teeth and implant placement.210 In most cases, pathological fractures often result from osteoradionecrosis of the jaw (ORN), osteomyelitis and severe which may be benign or malignant. Recent reports state that bisphosphonate-related osteonecrosis of the jaws is also considered as one of the etiologies of pathological fracture.211Pathological fractures of the jaw may be associated with severe pain and discomfort along with difficulty in eating and swallowing. Patients with pathological fractures normally require active treatments in order to restore the bone rigidity and establish the proper movement and function of the jaw.

Management of patients with suspected pathological fractures should be done by careful examination of the patients clinically and radiographically, followed by immediate evaluation by specialists such as oral and maxillofacial surgeons. It was previously stated that a dental practitioner may be the first health care practitioner to diagnose a patient with a pathological fracture of the jaw, indicating their important role in the management of pathological fractures of jaw.2 Management of jaw fractures may differ depending on the anatomical sites of the jaw due to the difference in biomechanics, treatment requirements and complications. Recent advancements in the management of jaw fractures have resulted in reduced risk of and biological stable fixation of bone segments, which allows for rapid bony union, proper restoration of occlusion and reduces the requirement for wire maxillomandibular fixation. Intermaxillary fixation is often done before fracture reduction which utilizes occlusion to help in anatomical reduction of the fracture.12 Various risk factors need to be considered prior to making the treatment decision which includes age, weight, history of fracture, , underlying diseases and habits.13 Previously our department has published extensive research on

1381

COMPETITIVE STRATEGY MODEL AND ITS IMPACT ON MICRO BUSINESS UNITOF LOCAL DEVELOPMENT BANKSIN JAWA PJAEE, 17 (7) (2020)

various aspects of prosthetic dentistry 14–24, this vast research experience has inspired us to research the pathological fractures and the importance of understanding its basic concept by dental students.

MATERIALS AND METHOD A questionnaire-based study was conducted involving students of Saveetha Dental College and Hospital, Chennai, India for a period of January 2020 to March 2020. Two examiners were involved in this study. A total of 100 participants took part in the survey.The inclusion criteria of this study were dental students ranging from third years to post-graduates with personal experiences of working in a dental setting. First and second year dental students and non-dental students were excluded from this study. All the participants were provided with a list of 10 questions related to pathological fractures. Data was collected and statistical analysis was done. Tabulation and analysis of the collected data were done using Statistical Package for Social Sciences for Windows version 23.0 (SPSS Inc., Chicago, IL, USA). Descriptive analysis was done to assess the awareness of dental students on pathological fractures based on their responses for each question provided.

RESULTS AND DISCUSSION Our present study reveals that 35% of the participants have experienced treating patients with pathological fracture while the remaining 65% have not encountered such patients previously. [Figure 1] According to Kim et al., the choice of treatment for pathological fractures is largely influenced by the experience of the operating as there is no standard protocol for pathologic fracture management especially in cases of post- operative radiation .25

Based on their knowledge on pathological fracture, 63% of the participants reveal that they are aware of the various factors that may lead to pathological fracture while the remaining 37% stated otherwise. [Figure 2] Pathological fracture often develops as a result of reduced bony strength which in turn may be caused by physiologic atrophy, such as and malignancy and . Some cases of pathological fractures occur secondary to surgical treatment such as removal of impacted molar.25 Basic knowledge on the factors associated with pathological factors helps in determining the ideal treatment plan adapted personally to each patient.13 Most studies indicate the difficulty in treating pathological fracture and may be different for each patient based on its etiology.2726 Based on a previous report, the rules of management are similar even if the treatment strategies differ from etiology to another.27

It can be seen that 60% of the participants are aware of the various treatment modalities available for the management of pathological fractures depending on numerous factors while the slightly lesser 40% of them are unsure of the proper treatment of pathological fractures. [Figure 3] A report by Yi Zhao et al., states that the management of pathological fracture particularly resulting from osteoradionecrosis is yet to be standardized, in which surgical resection and vascularized bone resection are currently accepted as the first choice of treatment in most cases.28 Bone resection is done until normal bleeding is obtained in. In the presence of sufficient normal bone such as cysts, traditional fracture reduction can be done followed by rigid maxillomandibular fixation.1

1382

COMPETITIVE STRATEGY MODEL AND ITS IMPACT ON MICRO BUSINESS UNITOF LOCAL DEVELOPMENT BANKSIN JAWA PJAEE, 17 (7) (2020)

Our study shows that only 58% of the participants are aware of the various complications associated with fracture management such as increased bone resorption and delayed wound healing while 42% of them stated otherwise. [Figure 4] A previous study states the presence of complications following fracture management as a result of delayed bone healing in the area of fracture after the placement of bone graft in patients subjected to preoperative radiation therapy. Another study reported on the increase in the rate of bone resorption following the placement of non-vascularized iliac bone graft.252930

Since most of the participants have no experience of treating patients with pathological fractures so far, 72% of them state that the occurrence rate of pathological fractures in a dental setting is low, 25% of them think its moderate and the other 3% think its high among dental patients. [Figure 5] According to Abir et al., pathological fracture of the mandible is rare, accounting for only 2% of all mandibular fractures.18 Another study stated the occurrence rate of pathological fracture of mandible is less than 1% of all fractures which further confirms the low incidence of pathological fracture.2831

By comparing the various etiologies associated with pathological fractures, 37% of the participants have chosen “osteoradionecrosis” as the most common etiology that may lead to fracture, “malignancy” by 35% of them and the remaining 28% picked “” as the main etiology which leads to pathological fractures among dental patients. [Figure 6] The results can be further supported by another study stating the common etiologies of pathological fractures to be osteoradionecrosis (49%), followed by infections (19%) and malignancy (19%). Various studies have reported osteoradionecrosis (ORN) as the most common cause of mandibular pathological fractures following radiotherapy due to its association with hypoxia, hypovascularity and hypocellularity according to the 3H theory of Marx that may lead to altered bone reparative capacity.32 However, a study by Abir at al., had proven otherwise by stating that most of the cases seen in his study were caused by malignancies, followed by ORN.18A previous study reported osteomyelitis as one of the common etiologies of pathological fracture (19%) following ORN (49%) which is usually associated with removal of impacted third molar or implants.13

Most of the participants are aware of the various management of pathological fractures since 61% of them are familiar with the terms “open reduction (OR)” and “closed reduction (CR)” while 39% are not familiar with the terms used in the treatment of pathological fractures. [Figure 7] According to Kim et al, management of pathological fractures is often similar to the treatments done for other types of fracture which includes open reduction and internal fixation (OR/IF) or closed reduction (CR).25 Basic knowledge on fracture management particularly on the subject of open reduction and closed reduction help dentists in proper treatment planning.

It can be seen that most of the participants have basic knowledge on pathological fracture as 84% of them have chosen closed reduction with intermaxillary fixation/intermaxillary elastic traction as the ideal treatment of pathological fracture in the mandible with osteomyelitis as compared to open reduction with rigid plate fixation which was selected by the other 16% of the participants. [Figure 8] This result is further supported by another report stating that the ideal treatment for pathological fracture of mandible with osteomyelitis is indeed closed reduction with intermaxillary fixation or intermaxillary elastic traction rather than open reduction with rigid plate fixation.82628

1383

COMPETITIVE STRATEGY MODEL AND ITS IMPACT ON MICRO BUSINESS UNITOF LOCAL DEVELOPMENT BANKSIN JAWA PJAEE, 17 (7) (2020)

Most of the participants stated that pathological fracture in the mandible usually occurs in the mandibular body (51%), 37% of them think that the condylar region is mainly affected in such condition while 12% of the participants have chosen angle/posterior molar region of the mandible which is usually associated with removal of unerupted tooth. [Figure 9] It was reported by Abir et al., that pathological fractures of the mandible are usually seen in the body of the mandible.131 Another study reported on the commonly affected sites being mandibular body (82.14%), followed by angle/posterior molar region (14.29%) and condyle (3.57%) respectively.283233Based on their current knowledge on pathological fractures, 55% are confident in treating patients with pathological fractures, while the other 45% are doubtful when it comes to their ability in managing patients with such conditions, mainly due to the lack of experience in the dental clinic. [Figure 10]

Table 1: Table showing the percentage results of responses for the questions related to the awareness on pathological fractures among dental students

No. Question Response Percentage

Do you have any experience of ● Yes 35 1. treating patients with ● No 65 pathological fracture?

2. Do you know the factors that ● Yes 63 may lead to pathological ● No 37 fractures?

Are you aware of the ● Yes 60 3. management of pathological ● No 40 fractures?

Do you know about the ● Yes 58 4. complications associated with ● No 42 fracture management?

1384

COMPETITIVE STRATEGY MODEL AND ITS IMPACT ON MICRO BUSINESS UNITOF LOCAL DEVELOPMENT BANKSIN JAWA PJAEE, 17 (7) (2020)

How would you rate the ● High 3 5. occurrence of pathological ● Moderate 25 fractures in a dental setting? ● Low 72

Which of the following is the ● Osteoradionecro 37 6. most common etiology of sis 28 pathological fracture? ● Infectious 35 ● Malignancy

Are you familiar with the terms ● Yes 61 7. open reduction (OR) and closed ● No 39 reduction (CR)?

8. Which of the following is ● Open reduction 16 considered as the ideal treatment with rigid plate of pathological fracture of the fixation mandible with osteomyelitis? 84 ● Closed reduction with intermaxillary fixation/intermaxi llary elastic traction

● Mandibular body 51 ● Angle / Posterior 12 9. Which of the following parts of molar region the mandible is commonly ● Condylar region 37 associated with pathological fracture?

1385

COMPETITIVE STRATEGY MODEL AND ITS IMPACT ON MICRO BUSINESS UNITOF LOCAL DEVELOPMENT BANKSIN JAWA PJAEE, 17 (7) (2020)

10. Are you confident in treating ● Yes 55 patients with pathological ● No 45 fracture?

Figure 1: Bar chart showing the responses to Question 1, “Do you have any experience of treating patients with pathological fracture?”. X axis represents the multiple answers provided. Y axis represents the number of individuals with each answer (Blue). A considerable proportion of the participants have experienced treating patients with pathological fracture (35%) while the remaining of them have not encountered such patients previously (65%).

1386

COMPETITIVE STRATEGY MODEL AND ITS IMPACT ON MICRO BUSINESS UNITOF LOCAL DEVELOPMENT BANKSIN JAWA PJAEE, 17 (7) (2020)

Figure 2: Bar chart showing the responses to Question 2, “Do you know the factors that may lead to pathological fractures?”. X axis represents the multiple answers provided. Y axis represents the number of individuals with each answer (Green). Most of the participants reveal that they are aware of the various factors that may lead to pathological fracture (63%) while the others stated otherwise (37%).

Figure 3: Bar chart showing the responses to Question 3, “Are you aware of the management of pathological fractures?”. X axis represents the multiple answers provided. Y axis represents the number of individuals with each answer (Purple). Most of the participants are aware of the various treatment modalities available for the management of pathological fractures depending on numerous factors (60%) while the minority of them are unsure of the proper treatment of pathological fractures (40%).

1387

COMPETITIVE STRATEGY MODEL AND ITS IMPACT ON MICRO BUSINESS UNITOF LOCAL DEVELOPMENT BANKSIN JAWA PJAEE, 17 (7) (2020)

Figure 4: Bar chart showing the responses to Question 4, “Do you know about the complications associated with fracture management?”. X axis represents the multiple answers provided. Y axis represents the number of individuals with each answer (Gold). Most of the participants are aware of the various complications associated with fracture management (58%) such as increased bone resorption and delayed wound healing while the remaining of them stated otherwise (42%).

Figure 5: Bar chart showing the responses to Question 5, “How would you rate the occurrence of pathological fractures in a dental setting?”. X axis represents the multiple answers provided. Y axis represents the number of individuals with each answer (Red).

1388

COMPETITIVE STRATEGY MODEL AND ITS IMPACT ON MICRO BUSINESS UNITOF LOCAL DEVELOPMENT BANKSIN JAWA PJAEE, 17 (7) (2020)

Most of the participants state that the occurrence rate of pathological fractures in a dental setting is low (72%), followed by moderate (25%) and high (3%) respectively.

Figure 6: Bar chart showing the responses to Question 6, “Which of the following is the most common etiology of pathological fracture?”. X axis represents the multiple answers provided. Y axis represents the number of individuals with each answer (Orange). Most of the participants have chosen osteoradionecrosis (37%) as the most common etiology that may lead to fracture, followed by malignancy (35%) and infections (28%) respectively.

Figure 7: Bar chart showing the responses to Question 7, “Are you familiar with the terms open reduction (OR) and closed reduction (CR)?”. X axis represents the multiple answers provided. Y axis represents the number of individuals with each answer (Yellow). Most of the participants (61%) are familiar with the terms “open reduction

1389

COMPETITIVE STRATEGY MODEL AND ITS IMPACT ON MICRO BUSINESS UNITOF LOCAL DEVELOPMENT BANKSIN JAWA PJAEE, 17 (7) (2020)

(OR)” and “closed reduction (CR)” while the remaining of them are not familiar with the terms (39%).

Figure 8: Bar chart showing the responses to Question 8, “Which of the following is considered as the ideal treatment of pathological fracture of mandible with osteomyelitis?”. X axis represents the multiple answers provided. Y axis represents the number of individuals with each answer (Grey). Most of the participants have chosen closed reduction with intermaxillary fixation/intermaxillary elastic traction as the ideal treatment of pathological fracture in the mandible with osteomyelitis (84%) when compared to open reduction with rigid plate fixation (16%).

Figure 9: Bar chart showing the responses to Question 9, “Which of the following parts of the mandible is commonly associated with pathological fracture?”. X axis represents

1390

COMPETITIVE STRATEGY MODEL AND ITS IMPACT ON MICRO BUSINESS UNITOF LOCAL DEVELOPMENT BANKSIN JAWA PJAEE, 17 (7) (2020)

the multiple answers provided. Y axis represents the number of individuals with each answer (Pink). It can be seen that most of the participants stated that pathological fracture in the mandible usually occurs in the mandibular body (51%), followed by condylar region (37%) and angle or posterior molar region of the mandible (12%) respectively.

Figure 10: Bar chart showing the responses to Question 10, “Are you confident in treating patients with pathological fracture?”. X axis represents the multiple answers provided. Y axis represents the number of individuals with each answer (Brown). Most of the participants are confident in treating patients with pathological fracture (55%) while the others are doubtful when it comes to their ability in managing patients with such conditions (45%).

Pathological fracture can be in the form of an acute or chronic long-standing condition affecting an individual due to various factors. Dentists play an important role in the management of pathological fracture as they may be the first health care practitioners in diagnosing patients with such conditions and making the first important step in providing treatment for these patients. Various reports have commented on the complexity of the treatments of pathological fractures due to their multiple etiologies, local bone status and general condition of the patient. Management of pathological fractures is usually done by treating the underlying pathological process prior to fracture management based on the bone condition, while patients with severe conditions are often treated by simple procedures. Proper treatment plans must be provided according to each individual‟s needs with the aim of maintaining the patient‟s quality of life.

CONCLUSION Within the limits of our study, it can be concluded that awareness about different management of jaw fractures among dental students is moderate and pathological

1391

COMPETITIVE STRATEGY MODEL AND ITS IMPACT ON MICRO BUSINESS UNITOF LOCAL DEVELOPMENT BANKSIN JAWA PJAEE, 17 (7) (2020)

fractures are one of the common factors that lead patients to the dental clinic. It is important for every dentist to have a basic understanding of pathological fracture and its management to provide a proper diagnosis and treatment plan for patients with such conditions.

ACKNOWLEDGEMENT We would like to thank Saveetha Dental College and Hospital for the contributions and involvement through this study.

CONFLICT OF INTEREST There was no conflict of interest.

REFERENCES 1. Abir B, Guerrouani A, Abouchadi A. Pathological fractures of the mandible: A report of ten cases and a review of the literature. Open Journal of Stomatology 2013; 03: 419–424. 2. Algahtani M, Alqudah M, Alshehri S, et al. Pathologic fracture of the mandible caused by metastatic follicular thyroid carcinoma. J Can Dent Assoc 2009; 75: 457–460. 3. Coletti D, Ord RA. Treatment rationale for pathological fractures of the mandible: a series of 44 fractures. Int J Oral Maxillofac Surg 2008; 37: 215–222. 4. Choi B-J, Choi SC, Kwon Y-D, et al. Aneurysmal bone causing a pathologic fracture of the mandibular condyle. J Oral Maxillofac Surg 2011; 69: 2995–3000. 5. Allan BP, Daly CG. Fractures of the mandible. A 35-year retrospective study. Int J Oral Maxillofac Surg 1990; 19: 268–271. 6. McGoldrick DM, McCarthy C, Sleeman D. Pathological fracture of the mandible. BMJ Case Rep; 2015. Epub ahead of print 16 April 2015. DOI: 10.1136/bcr-2014-208487. 7. Boffano P, Roccia F, Gallesio C, et al. Pathological mandibular fractures: a review of the literature of the last two decades. Dent Traumatol 2013; 29: 185–196. 8. Gerhards F, Kuffner HD, Wagner W. Pathological fractures of the mandible. A review of the etiology and treatment. Int J Oral Maxillofac Surg 1998; 27: 186–190. 9. Kainulainen Vt LT. Reconstruction of an extremely resorbed mandible by the „tent pole‟ procedure. Finnish Dental Journal 2003; 12: 591–597. 10. Meisami T, Sojat A, Sàndor GKB, et al. Impacted third molars and risk of angle fracture. International Journal of Oral and Maxillofacial 2002; 31: 140–144. 11. Brown DH, Evans AW, Sandor GKB. Hyperbaric Oxygen Therapy in the Management of Osteoradionecrosis of the Mandible. Hyperbaric Oxygen Therapy in 1998; 14–32.

1392

COMPETITIVE STRATEGY MODEL AND ITS IMPACT ON MICRO BUSINESS UNITOF LOCAL DEVELOPMENT BANKSIN JAWA PJAEE, 17 (7) (2020)

12. Bhagol A, Singh V, Singhal R. Management of Mandibular Fractures. A Textbook of Advanced Oral and Maxillofacial Surgery. Epub ahead of print 2013. DOI: 10.5772/53854. 13. Edwards BJ, Gounder M, McKoy JM, et al. Pharmacovigilance and reporting oversight in US FDA fast-track process: bisphosphonates and osteonecrosis of the jaw. The Lancet 2008; 9: 1166–1172. 14. Anbu RT, Suresh V, Gounder R, et al. Comparison of the Efficacy of Three Different Bone Regeneration Materials: An Animal Study. Eur J Dent 2019; 13: 22–28. 15. Ashok V, Ganapathy D. A geometrical method to classify face forms. J Oral Biol Craniofac Res 2019; 9: 232–235. 16. Ganapathy DM, Kannan A, Venugopalan S. Effect of Coated Surfaces influencing Screw Loosening in Implants: A Systematic Review and Meta-analysis. World Journal of Dentistry 2017; 8: 496–502. 17. Jain AR. Clinical and Functional Outcomes of Implant Prostheses in Fibula Free Flaps. World Journal of Dentistry 2017; 8: 171–176. 18. Ariga P, Nallaswamy D, Jain AR, et al. Determination of Correlation of Width of Maxillary Anterior Teeth using Extraoral and Intraoral Factors in Indian Population: A Systematic Review. World Journal of Dentistry 2018; 9: 68–75. 19. Evaluation of Corrosive Behavior of Four Nickel–chromium Alloys in Artificial Saliva by Cyclic Polarization Test:An in vitro Study. World Journal of Dentistry 2017; 8: 477–482. 20. Ranganathan H, Ganapathy DM, Jain AR. Cervical and Incisal Marginal Discrepancy in Ceramic Laminate Veneering Materials: A SEM Analysis. Contemp Clin Dent 2017; 8: 272–278. 21. Jain AR. Prevalence of Partial Edentulousness and Treatment needs in Rural Population of South India. World Journal of Dentistry 2017; 8: 213–217. 22. Duraisamy R, Krishnan CS, Ramasubramanian H, et al. Compatibility of Nonoriginal Abutments With Implants: Evaluation of Microgap at the Implant-Abutment Interface, With Original and Nonoriginal Abutments. Implant Dent 2019; 28: 289–295. 23. Gupta P, Ariga P, Deogade SC. Effect of Monopoly-coating Agent on the Surface Roughness of a Tissue Conditioner Subjected to Cleansing and Disinfection: A Contact Profilometric Study. Contemp Clin Dent 2018; 9: S122–S126. 24. Varghese SS, Ramesh A, Veeraiyan DN. Blended Module-Based Teaching in Biostatistics and Research Methodology: A Retrospective Study with Postgraduate Dental Students. J Dent Educ 2019; 83: 445–450. 25. Kim C-M, Park M-H, Yun S-W, et al. Treatment of pathologic fracture following postoperative radiation therapy: clinical study. Maxillofacial Plastic and Reconstructive Surgery; 37. Epub ahead of print 2015. DOI: 10.1186/s40902-015-0032-2. 26. Ogasawara T, Sano K, Hatsusegawa C, et al. Pathological fracture of the mandible resulting from osteomyelitis successfully treated with only

1393

COMPETITIVE STRATEGY MODEL AND ITS IMPACT ON MICRO BUSINESS UNITOF LOCAL DEVELOPMENT BANKSIN JAWA PJAEE, 17 (7) (2020)

intermaxillary elastic guiding. Int J Oral Maxillofac Surg 2008; 37: 581– 583. 27. Chrcanovic BR, Custódio ALN. Mandibular fractures associated with endosteal implants. Oral and Maxillofacial Surgery 2009; 13: 231–238. 28. Zhao Y, Li R-F, Sun Y-F, Liu B, Jia J. Pathological Fractures of the Mandible: A Report of 27 Cases. 2017; 2: 1839. Clin Surg 2017; 2: 1839. 29. Tidstrom KD, Keller EE. Reconstruction of mandibular discontinuity with autogenous iliac bone graft: report of 34 consecutive patients. J Oral Maxillofac Surg 1990; 48: 336–46; discussion 347. 30. Handschel, J., Hassanyar, H., Depprich, R.A., Ommerborn, M.A., Sproll, K.C., Hofer, M., Kuebler, N.R. and Naujoks, C. Nonvascularized iliac bone grafts for mandibular reconstruction–requirements and limitations. In Vivo 2011; 25: 795–799. 31. Ezsias A, Sugar AW. Pathological fractures of the mandible: a diagnostic and treatment dilemma. British Journal of Oral and Maxillofacial Surgery 1994; 32: 303–306. 32. Marx RE. A new concept in the treatment of osteoradionecrosis. J Oral Maxillofac Surg 1983; 41: 351–357. 33. Jia J, Zhang W-F, Liu B, et al. Pathological fracture of condyle from metastatic breast adenocarcinoma. Oral Oncology Extra 2006; 42: 98–100.

1394