Sir, we wish to present an interesting case of osteonecrosis of the jaw.

A 41-year-old female underwent general anaesthesia for hysterectomy. She had no history of treatment with bisphosphonates or radiation to the head and neck region. After recovery from general anesthesia, she started to feel pain from her right mandible. Twenty-two days after the general anaesthesia she went to her dentist for examination due to persisting pain. Examination revealed a mucosal ulcer and local bone exposure at the right mylohyoid ridge close to a mandibular tori. The patient was referred to an oral surgeon due to suspected oral malignancy. Seventeen days later (39 days after anaesthesia) the patient had a spontaneous exfoliation of a bone sequestrum in her mouth, and her symptoms declined almost immediately. At the time of examination by the oral surgeon (three days after exfoliation of the sequestrum), the ulcer was healing (Fig. 1). A CT scan showed signs of an exfoliated bone sequestrum (Fig. 2). Complete healing and absence of symptoms were confirmed 50 days after anaesthesia.

Figure 1
figure 1

A healing ulcer located at lingual shelf of the right mandible, on the posterior aspect of a mandibular tori

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Figure 2
figure 2

CT scan showing reduced amount of bone after spontaneous exfoliation of a sequestrum on the lingual shelf of the right mandible

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To our knowledge, only six cases with the same complication of general anaesthesia as described here have previously been reported, and never in a dentistry journal.1,2 We believe that this type of injury could either be caused by soft tissue necrosis due to local pressure from the endotracheal tube, or by soft tissue injury caused by the angulation and insertion of the laryngoscope, which could explain why patients are always affected on the lingual side of the right mandible.2 The blade of the laryngoscope is sharp and usually held in the left hand of the operator while inserted into the oral cavity along the right side of the mandible. In almost all reported cases, symptoms emerge directly after recovery from general anaesthesia or within a day.

Patients with large mandibular tori are at particular risk. Careful oral manipulation and use of techniques to facilitate laryngoscopy could possibly reduce the risk of oral trauma.3 Patients affected by this complication need to be followed until healing is confirmed (within 1-8 weeks). In selected cases, minimal surgical intervention may be needed to remove sequestered bone, to provide pain relief and to reduce the time required for healing.