Int. J. Oral Maxillofac. Surg.

2014; 43: 12431250

http://dx.doi.org/10.1016/j.ijom.2014.07.014, available online at http://www.sciencedirect.com

Systematic Review Paper

Trauma

Locking versus non-locking

plate fixation in the
management of mandibular
fractures: a meta-analysis

B. R. Chrcanovic
Department of Prosthodontics, Faculty of
Odontology, Malmo University, Malmo,
Sweden

B. R. Chrcanovic: Locking versus non-locking plate fixation in the management of

mandibular fractures: a meta-analysis. Int. J. Oral Maxillofac. Surg. 2014; 43: 1243
1250. # 2014 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

Abstract. The aim of the present study was to test whether there is a significant
difference in the clinical outcomes between locking and non-locking plate fixation
in the management of mandibular fractures. An electronic search without time or
language restrictions was undertaken in December 2013. Eligible studies were
clinical human studies, either randomized or not. The search strategy identified 10
publications. The I2 statistic was used to express the percentage of the total variation
across studies due to heterogeneity. The inverse variance method was used for the
random-effects model in the case of heterogeneity being detected, or the fixedeffects model in the case of heterogeneity not being detected. The estimates of an
intervention were expressed as the risk ratio (RR) with 95% confidence interval.
Eight studies were judged to be at high risk of bias, whereas two studies were
considered at moderate risk of bias. There was no statistically significant effect on
the outcome of postoperative infection (P = 0.17), malocclusion (P = 0.15),
hardware failure (P = 0.77), hardware removal (P = 0.95), wound dehiscence
(P = 0.98), or paraesthesia (P = 0.20) in favour of locking plate fixation. The test for
overall effect showed that the difference between the procedures did not
significantly affect the incidence of postoperative complications (P = 0.21), with
RR 0.79 (95% CI 0.541.14).

About 1940% of all facial fractures are

fractures of the mandible.15 Mandibular
fractures (MFs) can cause a variety of
impairments, including temporomandibular joint syndrome, malocclusion, poor
mastication, salivary disorders, obstructive sleep apnoea, and chronic pain. In
children, mandibular fractures can alter
0901-5027/01001243 + 08

facial development as well as being disfiguring and debilitating.6 Thus, there is a

widely accepted consensus regarding the
need for surgical reduction and fixation of
MFs. A variety of different treatment modalities have been described.79 Over the
last decades the management of MFs has
changed from maxillomandibular fixation

Key words: mandibular fracture; locking plate;

non-locking plate; standard plate; complications; meta-analysis.
Accepted for publication 18 July 2014
Available online 10 August 2014

(MMF) with or without internal wire fixation to internal plate and/or screw fixation
and no MMF. Research continues to focus
on the size, shape, number, and biomechanics of plate/screw systems to improve
surgical outcomes.8
Even though the locking plate and
screw system has been available for more

# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

1244

Chrcanovic

than three decades,10 there has recently

been renewed interest in these systems,
with a growing number of clinical studies.
With conventional bone plating systems,
stability is achieved when the head of the
screw compresses the fixation plate to the
bone. The plate must be perfectly adapted
to the underlying bone to prevent alterations in the alignment of the segments and
changes in the occlusal relationship.11 The
locking system uses a screw that locks not
only to the bone but also to the bone plate.
This is accomplished by having a screw
with a double thread. One thread will
engage the bone and another will engage
a threaded area of the bone plate. The
result is a locking plate system that in
effect provides a mini internal fixator.12
Haug et al.11 performed a biomechanical study comparing the systems with
intentional maladaptation of the plates.
They concluded that the degree of adaptation affected the mechanical behaviour of
non-locking systems, but it did not affect
the locking systems. Thus, it can be suggested that it becomes unnecessary for the
plate to have intimate contact with the
underlying bone, making plate adaptation
easier. Other theoretical proposed advantages of the locking plate/screw systems
over conventional plates and screws include less screw loosening, greater stability across the fracture site, less precision
required in plate adaptation because of the
internal/external fixator, and less alteration in osseous or occlusal relationship
upon screw tightening.13 The main disadvantage of the locking system is cost13 and
minor additions to the instrumentation
required.11
As the philosophies related to the treatment of maxillofacial trauma alter over
time, a periodic review of the different
concepts is necessary to refine techniques
and eliminate unnecessary procedures.
This would form the basis for optimum
treatment. Thus, in the face of all these
reported advantages of the locking system,
the objective of this study was verify
whether there is a significant difference
in the clinical outcomes between locking
and non-locking plate fixation in the management of MFs. A systematic review and
meta-analysis of prospective studies published in the dental literature up to and
including December 2013 was conducted.
Materials and methods
Objective

The purpose of the present review was to

test the null hypothesis of no difference
in the incidence of postoperative

complications for mandibular fractures

being fixed by locking or by non-locking
plates, against the alternative hypothesis
of a difference.

The following were excluded: case

reports, technical reports, animal studies,
in vitro studies, and review papers.
Study selection

Search strategies

An electronic search without time or language restrictions was undertaken in December 2013 in the following databases:
PubMed, Web of Science, and the
Cochrane Oral Health Group Trials Register. The following terms were used in the
search strategy: {Subject AND Adjective}{Subject: (mandibular fracture [text
words]) AND Adjective: (locking plate
OR non-locking plate OR nonlocking
plate OR standard plate OR conventional
plate [text words])}.
The following terms were used in the
search strategy on Web of Science: {Subject AND Adjective}{Subject: (mandibular fracture [title]) AND Adjective:
(locking plate OR non-locking plate OR
nonlocking plate OR standard plate OR
conventional plate [title])}.
The following terms were used in the
search strategy on the Cochrane Oral
Health Group Trials Register: (mandibular
fracture AND (locking plate OR non-locking plate OR nonlocking plate OR standard plate OR conventional plate)).
A manual search of dental implantsrelated journals, including the British
Journal of Oral and Maxillofacial Surgery,
International Journal of Oral and Maxillofacial Surgery, Journal of Craniofacial
Surgery, Journal of Cranio-Maxillofacial
Surgery, Journal of Maxillofacial and Oral
Surgery, Journal of Oral and Maxillofacial
Surgery, and Oral Surgery Oral Medicine
Oral Pathology Oral Radiology and Endodontology, was also performed.
The reference lists of the studies identified and relevant reviews on the subject
were also scanned for possible additional
studies. Moreover, online databases providing information about clinical trials
in progress were checked (clinicaltrials.
gov; www.centerwatch.com/clinicaltrials;
www.clinicalconnection.com).

Inclusion and exclusion criteria

Eligibility criteria included the following:

clinical human studies; randomized controlled trials (RCTs), controlled clinical
trials (CCTs), and retrospective studies;
comparison of the clinical outcomes of the
use of locking and non-locking plate fixation techniques in the management of
MFs; reported incidence of postoperative
complications.

The titles and abstracts were obtained for

all reports identified through the electronic
searches. For studies appearing to meet the
inclusion criteria, or for which there were
insufficient data in the title and abstract to
make a clear decision, the full report was
obtained.
Quality assessment

The quality assessment was performed

using the recommended approach for
assessing risk of bias in studies included
in Cochrane reviews.14 The classification
of the risk of bias potential for each study
was based on the following four criteria:
sequence generation (random selection in
the population), allocation concealment
(steps must be taken to secure strict implementation of the schedule of random
assignments by preventing foreknowledge
of the forthcoming allocations), incomplete outcome data (clear explanation of
withdrawals and exclusions), and blinding
(measures to blind study participants and
personnel from knowledge of which intervention a participant received). Incomplete outcome data was also considered
addressed when there were no withdrawals and/or exclusions. A study that met
all the criteria mentioned above was classified as having a low risk of bias. A study
that did not meet one of these criteria was
classified as having a moderate risk of
bias. When two or more criteria were
not met, the study was considered to have
a high risk of bias.
Data extraction and meta-analysis

The following data were extracted (when

available) from the studies included in the
final analysis: year of publication, study
design, number of patients, patient age
range and/or mean age, follow-up period,
number of MFs, region of MFs, fixation
methods, surgical approach, length of operation, postoperative MMF, use of antibiotics and/or chlorhexidine, number of
teeth retained and removed, mouth opening, inclusion criteria for fractures/
patients, postoperative radiological assessment, and postoperative complications. Authors were contacted for
possible missing data.
The postoperative complications evaluated were infection, postoperative disturbance in occlusion, hardware failure

Locking vs. non-locking plates

(fracture or loosening), segmental mobility, malunion, non-union, wound dehisinferior
alveolar
nerve
cence,
paraesthesia, and hardware removal, all
dichotomous outcomes. The statistical
unit for postoperative complications
was the number of mandibular fractures
fixed by one of the two fixation methods.
Weighted mean differences were used to
evaluate the continuous outcome length
of operation. Whenever outcomes of interest were not clearly stated, the data
were not used for analysis. The I2 statistic
was used to express the percentage of the
total variation across studies due to heterogeneity, with 25% corresponding to
low heterogeneity, 50% to moderate,
and 75% to high. The inverse variance
method was used for the random-effects
or fixed-effects model. Where statistically
significant (P < 0.10) heterogeneity was
detected, a random-effects model was
used to assess the significance of treatment
effects. Where no statistically significant
heterogeneity was found, the analysis was
performed using a fixed-effects model.15
The estimates of an intervention were
expressed as the risk ratio (RR) with
95% confidence interval (CI). Only if
there were studies with similar comparisons reporting the same outcome measures
was a meta-analysis to be attempted.
A funnel plot (plot of effect size versus
standard error) was drawn. Asymmetry of
the funnel plot may indicate publication
bias and other biases related to sample
size, although asymmetry may also represent a true relationship between trial size
and effect size.
The data were analyzed using the statistical software Review Manager (version
5.2.7, The Nordic Cochrane Centre, The
Cochrane Collaboration, Copenhagen,
Denmark, 2012).
Results
Literature search

The study selection process is summarized

in Fig. 1. The search strategy resulted in
669 entries. The initial screening of titles
and abstracts resulted in 36 full-text
papers; 12 were cited in more than one
research of terms. The full-text reports of
the remaining 24 articles led to the exclusion of 15 because they did not meet the
inclusion criteria: 11 articles were in vitro
biomechanical studies, two articles did not
provide information on the number of MFs
in each group, one study compared the
different osteosynthesis techniques but for
fixation of osteotomies after tumour ablation surgery, and one study was performed

1245

Fig. 1. Study screening process.

in animals (in vivo). Additional handsearching of the reference lists of selected

studies yielded one additional paper. Thus,
a total of 10 publications were included in
the review.
Description of the studies

Detailed data of the 10 included studies

are listed in Table 1. Eight RCTs13,1622
and two retrospective studies23,24 were
included in the meta-analysis.
Most studies excluded comminuted
fractures, with the exception of two.19,21
In total 471 patients were enrolled in the
10 studies, with 310 MFs in the locking
plates group and 312 MFs in the nonlocking plate group. The maximum follow-up period varied between 1 and 57
months. Four studies followed the patients
up to 48 weeks,16,19,22,23 whereas four
other studies observed the patients up to 3
months.18,20,21,24
Concerning the non-locking plate
group, eight studies13,1620,22,24 performed
the fixation using a 2.0-mm miniplate,
whereas one study23 used a 2.5-mm plate
and one study21 a 2.7-mm plate. Concerning the locking plate group, seven studies13,1618,20,23,24 performed the fixation
using a 2.0-mm locking miniplate, whereas two studies19,22 used a 3D 2.0-mm
locking miniplate and one study21 used
a 2.4-mm locking miniplate.
Four studies16,18,21,24 did not provide
information on the type of surgical
approach used. Four studies19,20,22,23

exclusively used the intraoral approach.

Two studies13,17 used more than one approach.
Four studies13,16,19,22 provided information on the mean operation time. Only four
studies16,20,22,23 reported whether prophylactic antibiotics were used or not, and
only two16,23 reported the use of chlorhexidine rinse. Postoperative MMF was not
performed in three studies,17,19,22 whereas
in four studies MMF was postoperatively
maintained
in
some
of
the
patients16,20,23,24 and in two studies13,18
it was performed in all patients. One
study21 did not mention whether MMF
was performed or not. None of the studies
provided information about mouth opening. Information on postoperative radiological assessment was provided in only
two articles,20,22 and both stated that there
was no significant difference in reduction
and fixation between the two groups.
Quality assessment

Each trial was assessed for risk of bias, and

the scores are summarized in Table 2.
Eight studies13,16,1821,23,24 were judged
to be at high risk of bias, whereas two
studies17,22 were considered at moderate
risk of bias.
Meta-analysis

The forest plots for the effect of the intervention are shown in Fig. 2. There was
an absence of heterogeneity among the

1246

Table 1. Studies comparing locking and non-locking fixation techniques in the management of mandibular fractures.
Patient age
range, years
(average)

Authors and
year published

Study
design

Follow-up
period, range

Collins
et al. (2004)13

RCT
(single
centre)

90 (NM)

1458
(25.9  6.7)

6 weeks

Saikrishna
et al. (2009)16

RCT
(single
centre)

40 (G1 20;
G2 20)

1560 (NM)

1 day, 3 days,
6 weeks

Seemann
et al. (2009)17

RCT
(multicentre)

129 (NM)

NM
(37.2  17.5)

57 weeks,
57 months

Agarwal
et al. (2011)18

RCT
(single
centre)

20 (G1, 10;
G2, 10)

NM

Baig
et al. (2011)23

RA
(single
centre)

20 (G1, 10;
G2, 10)

1940 (27)

1
3
6
3
1
2
6

Goyal
et al. (2011)19

RCT
(single
centre)

30 (G1, 15;
G2, 15)

1660 (NM)

3, 15, and
30 days

Singh
et al. (2011)20

RCT
(single
centre)

50 (G1, 25;
G2, 25)

1652
(30  8.5)

Weekly for
46 weeks,
2 and
3 months

Harjani
et al. (2012)21

RCT
(single
centre)

12 (G1, 6;
G2, 6)

NM

1, 3, 6,
and 12 weeks

Jain
et al. (2012)22

RCT
(multicentre)

20 (G1,
10; G2, 10)

1660 (NM)

1, 2, 4, 6,
and 8 weeks

Kumar
et al. (2013)24

RA
(single
centre)

60 (G1, 30;
G2, 30)

NM (28)

Weekly for
46 weeks,
2 and
3 months

week,
weeks,
weeks,
months
week,
weeks,
weeks

Number of MFs and

region of MFs (n)
N = 122
Parasymphysis
(G1, 26; G2, 30)
Body (G1, 9; G2, 7)
Angle (G1, 29; G2, 21)
N = 59
Symphysis (G1, 5; G2, 3)
Parasymphysis
(G1, 12; G2, 10)
Body (G1, 5; G2, 5)
Angle (G1, 6; G2, 13)
N = 146
Condyle (G1, 72; G2, 74)

N = 34
Parasymphysis was the
most commonly involved
site, followed by the angle.
N = 26
Symphysis (G1, 3; G2, 0)
Parasymphysis
(G1, 7; G2, 10)
Bodya (G1, 1; G2, 0)
Anglea (G1, 1; G2, 4)
N = 45
Parasymphysis (9)
Body (14)
Angle (21)
NM (1)
N = 76
Parasymphysis
(G1, 6; G2, 10)
Body (G1, 13; G2, 15)
Angle (G1, 13; G2, 13)
Condyle (G1, 4; G2, 2)
N = 12
NM

N = 20
Interforaminal
fractures
(G1, 10; G2, 10)
N = 88
Parasymphysis (20)
Body (24)
Angle (44)

MF fixation methods
(number of fractures)

Surgical
approach

G1: 2.0-mm locking

miniplate (n = 64)
G2: 2.0-mm standard
miniplate (n = 58)

Intraoral
(angle:
transbuccal)

G1: 2.0-mm locking

miniplate (n = 28)
G2: 2.0-mm standard
miniplate (n = 31)

NM

G1: 2.0-mm locking

miniplate (n = 72)
G2: 2.0-mm standard
miniplate (n = 74)
G1: 2.0-mm locking
miniplate (n = 18)
G2: 2.0-mm standard
miniplate (n = 16)
G1: 2.0-mm locking
miniplate (n = 10)
G2: 2.5-mm standard
miniplate (n = 10)

Length of
operation,
min, mean

Postoperative
MMF (number
of patients)

Antibiotics/
chlorhexidine,
days

Teeth
retained/
removed
(in MFs)

Inclusion criteria

G1 + G2:
85.6  12.6
(6.5 min
shorter for
G1)
G1: 79.25
G2: 74.25

90 (for
4 weeks)

NM

NM

G1: 3
G2: 9

7/until
discharge

NM

Pre-auricular
(n = 56),
transoral
(n = 90)
NM

NM

NP

NM

NM

Non-comminuted fractures, no other facial fracture

NM

20
(710 days)

NM

NM

Non-comminuted and/or
non-infected fractures, no
other facial fracture

Intraoral

NM

G1: 6
G2: 6
(2 weeks)

7/frequently

NM

Non-comminuted and/or
non-infected fractures,
partially or totally dentate
patients, interforaminal
fractures

G1: 3D 6/8-hole 2.0-mm

locking miniplate (n = 22b)
G2: 2.0-mm standard
miniplate (n = 23b)

Intraoral

NP

NM

NM

Patients with comminuted

and malunited fractures
were also included

G1: 2.0-mm locking

miniplate (n = 36)
G2: 2.0-mm standard
miniplate (n = 40)

Intraoral

Angle (G1,
80; G2, 53)
Body (G1,
56; G2, 43)
Parasymphysis
(G1, 45; G2, 68)
NM

G1: 7
G2: 17
(for 5 days)

7/NM

Extraction of
teeth in the
line of fracture
was performed
if indicated

Non-comminuted and/or
non-infected fractures

G1: 2.4-mm locking

plate (n = 6)
G2: 2.7-mm standard
plate (n = 6)
G1: one 3D 4-hole 2.0-mm
locking miniplate (n = 10)
G2: two 2.0-mm standard
miniplates (n = 10)
G1: 2.0-mm locking
miniplate (n = 44)
G2: 2.0-mm standard
miniplate (n = 44)

NM

NM

NM

NM

NM

Intraoral

G1: 77
G2: 158

NP

3/NM

G1: 2/1
G2: 2/1

Patients with comminuted,

infected, pathological
fractures and continuity
defects were also included
Isolated non-comminuted
non-infected interforaminal fractures

NM

NM

G1: 8
G2: 20

NM

NM

MF, mandibular fracture; MMF, maxillomandibular fixation; G1, locking plate group; G2, non-locking plate group; RCT, randomized clinical trial; RA, retrospective analysis; NM, not mentioned; NP, not performed.
a
Treatment not being compared in these fractures.
b
Unpublished information was obtained by personal communication with one of the authors.

Non-comminuted fractures, dentition complete

enough to apply stable
Erich arch bars, no other
facial fracture
Non-comminuted and/or
non-infected fractures,
dentition complete enough
to apply stable Erich arch
bars

NM

Chrcanovic

Total
patients
(/group), n

Locking vs. non-locking plates

1247

Table 2. Results of quality assessment.

Authors
Collins et al.13
Saikrishna et al.16
Seemann et al.17
Agarwal et al.18
Baig et al.23
Goyal et al.19
Singh et al.20
Harjani et al.21
Jain et al.22
Kumar et al.24
a

Published

Sequence generation
(randomized?)

Allocation
concealment

Incomplete outcome
data addressed

Blinding

Estimated potential
risk of bias

Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No

Unclear
Unclear
Adequate
Unclear
Inadequate
Noa
Unclear
Unclear
Adequate
Inadequate

Yes
Yes
No
No
No
No
No
No
No
No

Unclear
Unclear
Yes
Unclear
No
Noa
Unclear
Unclear
Yes
No

High
High
Moderate
High
High
High
High
High
Moderate
High

2004
2009
2009
2011
2011
2011
2011
2012
2012
2013

Unpublished information was obtained by personal communication with one of the authors.

studies for all postoperative complications

being analyzed (I2 = 0%, P = 0.99), therefore a fixed-effects model was used. No
cases of malunion, non-union, or segmental mobility were reported. There was no
statistically significant effect on the outcome
of
postoperative
infection
(P = 0.17), malocclusion (P = 0.15), hardware failure (P = 0.77), hardware removal
(P = 0.95), wound dehiscence (P = 0.98),
or paraesthesia (P = 0.20) in favour of
locking plate fixation.
The test for overall effect did not reveal
a statistically significant advantage for the
locking plate when the incidence of all
postoperative complications was considered (RR 0.79, 95% CI 0.541.14;
P = 0.21). The test of heterogeneity
among all studies showed homogeneity
(x2 = 11.62, df = 25, P = 0.99; I2 = 0%),
as well as the test for subgroup differences
(inconsistency across the subgroups)
(x2 = 4.08, df = 5, P = 0.54; I2 = 0%).
The cumulative RR was 0.79, meaning
that the use of the locking plate in the
fixation of MFs decreases the risk (relative
risk reduction, RRR) of the event (postoperative complication) by 21%.
Concerning the length of operation, only four studies13,16,19,22 provided information on the mean operation time. However,
none of these reported the standard deviation, which is necessary for the calculation
of comparisons in continuous outcomes.
Thus, a comparison was not possible.
Publication bias

The funnel plot did not show asymmetry

(Fig. 3), indicating the absence of publication bias.
Discussion

Potential biases are likely to be greater for

non-randomized studies compared with
RCTs, so results should always be interpreted with caution when they are included
in reviews and meta-analyses.14 So what

was the reason to include non-randomized

studies in the present meta-analysis? This
issue is important because meta-analyses
are frequently conducted on a limited number of RCTs.25 Shrier26 reviewed a random
1% sample of meta-analyses published by
the Cochrane Collaboration in 2003 and
found that six of 16 reviews included two
studies or fewer. Furthermore, 158 of 183
analyses conducted in seven additional
studies were limited to two or fewer studies.
In meta-analyses such as these, adding
more information from observational studies may aid in clinical reasoning and in
establishing a more solid foundation for
causal inferences.25 In a meta-analysis, homogeneity implies a mathematical compatibility between the results of each
individual trial. Narrowing the inclusion
criteria increases homogeneity but also
excludes the results of more trials and thus
risks the exclusion of significant data.
Concerning the use of non-locking
systems, it has been stated that if the
implant is not perfectly moulded to the
anatomy of the subjacent bone, primary
loss of reduction occurs because of the
traction of the screw on the bone needed
for securing it to the Plate.11,24 Without
this intimate contact, tightening of the
screws will draw the bone segments
towards the plate, resulting in alterations
in the position of the osseous segments
and the occlusal relationship.27 Moreover, that secondary loss of reduction
is also more frequent in non-locking
systems, as the resulting loading forces
and micro-movements may lead to loosening of the screws and instability. In
both cases the consequence tends to be
malocclusion.24 In the locking system, as
the screws are tightened, they lock to
the plate, thus stabilizing the segments
without the need to compress the bone to
the plate. Ellis and Graham27 stated that
this obviates the risk that screw insertion
will alter reduction. However, the metaanalysis found no statistically significant
difference between the two groups

regarding postoperative malocclusion

(P = 0.15).
The theory of the locking screw plate
system is that the integration of screw and
plate will allow for more rigidity in the
plating system, hence decreased fixation
failure. The possible advantage of this
property of a locking plate/screw system
is a decreased incidence of loosening of
the hardware.27 Once again, the metaanalysis found no statistically significant
difference between the two groups regarding hardware failure (P = 0.77).
Another alleged advantage of a locking
plate/screw system is a decreased incidence
of inflammatory complications from loosening of the hardware. It is known that loose
hardware propagates an inflammatory response and promotes infection.27 The present meta-analysis found no statistically
significant difference between the two plate
systems regarding postoperative infection
(P = 0.17). This may be explained by the
fact that the plate system is probably not the
only factor to influence the incidence of
postoperative infection. Moreno et al.28
reviewed 386 MFs treated with several
different plating systems. No significant
correlation between postoperative infection
and the type of treatment applied was observed. They suggested that other factors,
such the patients medical condition, oral
hygiene, complexity of the fracture, and
time from injury to treatment, were more
important with regard to postoperative infection than the type of plating system used.
All of these alleged possible advantages
of the locking system over the non-locking
systems were formulated based on the
results of biomechanical studies. The
results of experimental in vitro studies
provide a reasonable estimate of the rigidity and fixation strengths to be expected.29
However, they do not all correspond to
clinical outcomes, and biomechanics are
only one factor to consider when treating
fractures. Another limitation of the in vitro
models is that the relatively severe
testing configuration does not properly

1248

Chrcanovic

Fig. 2. Forest plots for the effect of intervention.

Locking vs. non-locking plates

1249

Fig. 3. Funnel plot of publication bias according to the reported incidence of postoperative complications.

acknowledge the stabilizing contribution

of the investing muscles.29 Moreover, a
confounding factor that could not be tested
in in vitro investigations is the additional
resistance to displacement of jagged fracture margins present in the human fracture.8
A short follow-up period is a limitation
of most studies, although it is hard to
define what should be considered a short
follow-up period to evaluate postoperative
complications in MFs. The presence of
associated mandibular fractures is a confounding risk factor, as well as the use of
reconstruction locking plates in one
study,21 the missing information on antibiotic prophylaxis in most studies, and the
variable use of postoperative MMF. The
use of MMF after fracture reduction
versus allowing immediate function might
further influence success rates.30 The relationship between the severity of the fracture and the complication rate it is also
worth mentioning. Two studies19,21 did
not exclude comminuted MFs. If due to
the severity of the fracture the bone quantity or quality is poor, decreased strength
and increased failure are likely, regardless
of the system used.30 Moreover, the
comparisons between the plating systems

were performed in fractures located in

different mandibular regions, depending
on the study. For example, Baig et al.23
and Jain et al.22 compared the fixation
systems only in interforaminal fractures,
whereas Seemann et al.17 evaluated the
different systems only in condylar fractures. Different mandibular subunits and
changing bite-loading locations are prone
to different patterns of fracture displacement, which can also influence the success
rates. These variables may have affected
the outcome and not just the subjection of
the MFs to fixation using one system or the
other one, and the impact of these variables on the postoperative complication
rates is difficult to estimate. A greater
level of statistical significance might have
been realized had the confounding variables not been present.
Due to the fact that the biomechanical
study of Chiodo et al.30 did not show any
statistically significant difference between
the two plate designs concerning failure
strength when placed in an identical manner (despite the fact that other biomechanical studies11,3133 have shown the locking
screw system to be more rigid and to
provide greater resistance to displacement
than conventional plates), the authors30

hypothesized that the most dependent variable affecting the performance of the two
different systems may not necessarily be
the type of fixation system, but other
variables that may include plate adaptation and screw placement, bone quantity,
bone quality, drilling conditions, and postoperative patient compliance. Moreover,
the authors also stated that a well-adapted
conventional mandibular plate should
function as well as a locking plate in the
appropriate circumstances. However,
placement of fracture fixation hardware
is a fluid process. In the laboratory all
conditions can be controlled easily,
whereas in the operating room, the surgeons are rarely so lucky.30
Having said that, when selecting a fixation scheme for a fracture one has to
consider many things such as the size,
number of fixation devices, their location,
ease of adaptation and fixation, biomechanical stability, the surgical approach, and the amount of soft tissue
disruption necessary to expose the fracture
and place the fixation devices.22
In conclusion, despite the significant
theoretical advantages of the locking system seen in biomechanical studies, the
results of the present meta-analysis failed

1250

Chrcanovic

to show statistically significant differences

in postoperative complication rates with
the use of locking screw/plate systems
when compared to the use of non-locking
systems in the management of MFs.
Funding

None.
Competing interests

None declared.
Ethical approval

Not required.
Patient consent

Not required.
Acknowledgement. The author would like
to thank Dr. Manoj Goyal, who provided
some missing information about his study.

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Address:
Bruno Ramos Chrcanovic
Department of Prosthodontics
Faculty of Odontology
Malmo University
Carl Gustafs vag 34
SE-205 06 Malmo
Sweden
Tel: +46 725 541 545; Fax: +46 40 6658503
E-mails: bruno.chrcanovic@mah.se,
brunochrcanovic@hotmail.com