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Int. J. Oral MaxilloJhc. Surg. 1999; 28:243~52 Printed flz Denmark. All rights reserved

Treatment methodsfor fractures of the mandibular angle

E. Ellis III. Treatment methods for fractures of the mandibular angle. Int. J. Oral

Maxillofac.

Surg. 1999, 28." 243~52.

9 Munksgaard,

1999

Abstract. Fractures of the mandibular angle are plagued with the highest rate of complication of all mandibular fractures. Over the past 10 years, various forms of treatment for these fractures were performed on an indigent inner city population. Treatment included: 1) closed reduction or intraoral open reduction and non-rigid fixation; 2) extraoral open reduction and internal fixation with an AO/ASIF reconstruction bone plate; 3) intraoral open reduction and internal fixation using a solitary lag screw; 4) intraoral open reduction and internal fixation using two 2.0 mm mini-dynamic compression plates; 5) intraoral open reduction and internal fixation using two 2.4 mm mandibular dynamic compression plates; 6) intraoral open reduction and internal fixation using two non-compression miniplates; 7) intraoral open reduction and internal fixation using a single non-compression miniplate; and 8) intraoral open reduction and internal fixation using a single malleable non-compression miniplate. This paper reviews the results of those modes of treatment when used for the same patient population at one hospital. Results of treatment show that, in this patient population, the use of either an extraoral open reduction and internal fixation with the AO/ASIF reconstruction plate or intraoral open reduction and internal fixation, using a single miniplate, are associated with the fewest complications.

Fractures of the mandibular angle rep- resent the largest percentage of man- dibular fractures in many studies. The

etiology of the injury has something to do with the location of the mandible that fractures. Fractures sustained in altercations show a high incidence of

fractures

dible33'4~176

thought is that a blow to the lateral portion of the mandible causes a frac- ture at that point, and commonly a fracture on the opposite body/symphy- sis region. Why is the angle of the mandible commonly associated with fractures? There are several proposed reasons that include: 1) the presence of third molars; 2) a thinner cross-sectional area than the tooth-bearing region; and 3) bio-

prevailing

of

the

angle

of

the

man-

The

mechanically the angle can be con- sidered a "lever" area. Several authors have implicated the presence of third molars, especially impacted third mo- lars, as a reason for mandibular frac-

tures occurring in the region of the angle. In fact, some have recommended prophylactic removal of third molars to eliminate their weakening effect in the

angle

fractures from occurring 1,2,39'61'64'68.

While this seems an extreme stance on the issue, there is scientific evidence in- dicating that third molars do weaken the angle of the jaw and are associated with fractures more commonly than when no tooth is present. For instance,

a study by REITZlK et al. s3 found mon-

key mandibles with unerupted third molars fractured at 60% of the force re-

region,

in

hopes

of

preventing

Copyright 9 Munksgaard 1999

Intemadona]Joumal of

Oral8r

Maxill@cialSurgery

ISSN 090t-5027

Leading article

Edward Ellis III Oral and Maxillofacial Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA

Key words: mandibular fracture; bone plates; fracture fixation.

Accepted for publication 24 January 1999

quired when no tooth was present, Clin- ical investigations have shown that pa- tients with third molars present are more likely to sustain fractures of the angle than when no tooth is pres- ent s6,7~ Further, the amount of space occupied by the third molar was found to directly relate to weakness in that re- gion of the mandible56, One would logically expect fractures to occur at points of greatest weakness in a structure. One would also logically expect that thinner cross-sectional areas of a structure would be weaker than those areas with greater cross-sectional areas. A study by SHVBERT et al. 63 has shown that the region of the mandibu- lar angle is thinner than both the bone of the body region located more anteri- orly, and the bone of the ramus located

244

Ellis

more posteriorly. Thus, a given force applied to the lateral aspect of the man- dible might be expected to fracture at the region with the smallest cross-sec- tional area the angle of the mandible. Combine this with the fact that the angle of the mandible is where there is an abrupt change in shape from hori- zontal to vertical rami, which would im- ply that this region might be subjected to more complex forces than a more lin- ear geometric shape, and one can begin to understand why fractures occur in this location. Fractures of the mandibular angle represent an important clinical chal- lenge because their treatment is plagued with the highest postsurgical compli-

frac-

tures 16,34,36,s9,72. Even traditional treat-

ment methods have a high complication rate in some patient populations49. With the introduction and popularity of plate and screw fixation over the past 30 years, a number of fixation methods have been advocated for the treatment of fractures occurring through the angle of the mandible. Many of these tech- niques are seemingly disparate. For in- stance, the AO/ASIF originally felt that plate and screw fixation should provide sufficient rigidity to the fragments to prevent interfragmentary mobility dur- ing active use of the mandible66,67. LUItR42 similarly recommended large bone plates, usually with compression, fastened with bicortical bone screws to provide such rigidity. Primary bone union, which necessitates absolute im- mobility of fragments, is the goal of treatment of mandibular fractures by these surgeons. In 1973, MICHELET et al. 45 reported on the treatment of mandibular frac- tures using small, easily bendable non- compression bone plates, placed trans- orally, attached with monocortical screws. The application of this tech- nique was a seeming dichotomy to the more widely accepted dictum of rigid fixation, and sparked a revolution in the treatment of facial fractures. CHAMPYet al.8 12 performed several investigations with a "miniplate" system to validate the technique, in their experiments, they determined the "ideal lines of os- teosynthesis" in the mandible, or the locations where bone plate fixation should provide the most stable means of fixation. For fractures of the man- dibular angle, the most effective plate location was found to be along the su- perior border of the mandible. Because

cation

rate

of

all

mandibular

the bone plates were small and the

screws inserted monocortically, fixation could be applied in this most mechanic- ally advantageous area without damag- ing teeth. Unlike the AO/ASIF sur- geons and LUHR, absolute immo- bilization of bone fragments and primary bone union was deemed un- necessary. Clinical studies since have

proven

nique7,24,26,27,29,31,47,51,73

the

usefulness

of

this

tech-

Questions about the degree of sta-

bility provided by these "mini-plates" have become a point of contention among surgeons. RAVEH et al. 52,

LUHR44 and

not feel that the plates offer adequate stabilization of the fracture to eliminate the need for intermaxillary fixation. Other surgeons who routinely used the more rigid AO/ASIF plates began to re- lent and use miniplates26'27. Unfortunately, whether or not one method is "superior" to another is diffi- cult to determine. Studies in the litera- ture vary widely in the rates of compli- cation reported when treating fractures of the angle. For instance, LUHR & HAUSMANN43 report a 0.9% rate of com- plications in 352 patients treated by compression plates for fractures of the angle, whereas ELLIS & SINN22 report a 32% rate of complication in 65 patients treated with compression plates for angle fractures. IIZUKA & L1NDQVIST35 reported a 6.6% rate of infection and a 14% rate of malocclusion for 121 frac- tures of the angle. Analysis in that study showed that complications were most re- lated to the use of compression and two points of fixation. How can rates of complication be so varied? There are several problems when one attempts to compare treatment methods for fractures of the mandibular angle. The first difficulty is that there are few studies that restrict their focus to fractures of the mandibular angle. Most studies evaluatingresults for mandibular fractures include fractures in all regions of the mandible, making it difficult to de- termine the actual rate of complication for angle fractures. Another problem is that treatment in one country may be very different from treatment in another. For instance, patients treated for man- dibular fractures in some of the Euro- pean countries may spend 7 21 days in hospital after surgery. In the United States, they are usually discharged the same or the next day. It is therefore doubtful that the quality and quantity of postsurgical care is similar. Studies also

AO/ASIF advocates 4 do

vary in the etiology of the injury. Studies from the United States generally have samples drawn from large inner-cityhos- pitals where most of the injuries result from interpersonal violence, in many European, Middle Eastern and Asian studies, motor vehicle-related injuries are more common. Hand in hand with the cause of the injury is the socioecon- Omic status of the patients. Those in- jured by interpersonal violence and treated in major inner-city hospitals in the United States tend to be poor, with poor oral hygiene and a poor state of dentition. Those patients whose frac- tures are sustained in motor vehicle acci- dents, sports or in bicycle accidents tend to be a higher socioeconomic group and are more concerned with oral and gen- eral health. There are also great differ- ences in the literature in what constitutes a complication. In countries where rout- ing removal of fixation devices is com- mon, soft tissue dehiscence with plate ex- posure may not be counted as a compli- cation because the plate will be removed anyway. In the United States, where plate removal is not routine, any un- planned intervention should be con- sidered a complication. Another major variable is in the number of surgeons in- volved in the operative intervention. Be- cause of these factors and a host of others, it becomes difficult to accurately assess treatment results with different fixation techniques. The following presents the experience of one faculty surgeon treating fractures of the mandibular angle at one insti- tution, with a consistent patient popu- lation, using eight different techniques. While a number of residents were in- volved in the surgeries, the same faculty member (E.E.) was present for over 95% of the actual open part of the oper- ations.

Methods

Over the past 10 years, various methods of treatment for fractures of the angle of the mandible have been studied at Parkland Memorial Hospital in Dallas, Texas.The con- tinuing quest for a simple but effective tech- nique droveus to use differentmodes of treat- ment and to examine their efficacy. The fol- lowing study relates our experience with several accepted methods for treating frac- tures of the mandibular angle19 25,49,51. The first two methods, closed reduction with or without non-rigid fixation, and the use of the AO/ASIF reconstruction plate, were retro- spectivestudies.All others wereprospectivein their data collection.With the exceptionof the extraoral approach used in those patients

treated with the AO/ASIF reconstruction plate, all techniques were intraoral, with the exception of transfacial trocar instrumen- tation. The population in these studies was largely inner-city indigent patients with poor den- titions and poor oral hygiene. The majority of the cases occurred in males (approximate- ly 85%). The racial/ethnic breakdown was approximately 50% African-Americans, 30% Non-Hispanic Caucasians, and 20% Hispan- ic. The average age of the patients was ap- proximately 27 years, with the vast majority in the third and fourth decades of life. Ap- proximately half of the angle fractures were isolated mandibular fractures; the other half having a contralateral fracture of the man- dibular condyle, angle, body or symphysis. All patients had arch-bars attached to the dentition during surgery but none of the pa- tients reported below were placed into post- surgical intermaxillary fixation (IMF) unless otherwise noted. However, the arch-bars were left in place until the patient was fnnctionally rehabilitated with an interincisal opening of greater than 40 ram. This usually was from 4 to 8 weeks post-surgery. All other fractures of the mandible (with the possible exception of subcondylar) were treated with plate and/ or screw fixation, allowing immediate man- dibular function. Even those patients who had closed treatment of condylar fractures were allowed immediate mobilization of the mandible, but may have had elastics applied to the dentition to "guide" them into proper occlusion. The vast majority of fractures in this patient population were sustained in altercations/assaults (approximately 85 95%). The time between injury and presen- tation for treatment ranged from a few hours to several weeks, with an average of approxi- mately 2.5 days. The average time between injury and surgery was just over 3 days. The data that were collected in each study included: 1) age, 2) sex, 3) race, 4) number of fractures per patient, 5) etiology, 6) associated maxillofacial or other system trauma, 7) type of fracture, i.e. comminuted versus linear, ob- lique versus straight, 8) concomitant man- dibular fractures, 9) presence of a tooth in the line of fracture, 10) extraction of tooth in line of fracture, 11) complications during surgery, 12) posts urgical occlusal relationship, and 13) complications, which were defined as a need for further surgical intervention. Only pa- tients with a minimum follow-up of six weeks were included. Approximately 80% of cases had a tooth associated with the fracture in the angle, and these were removed during surgery in 60 80% of cases.

Closed reduction or intraoral open reduction and non-rigid internal fixation

With the implementation of rigid forms of internal fixation, closed reduction or non-ri- gid internal fixation methods have become less fashionable. However, when assessing treatment results of new techniques, it is im- portant to have a group for comparison. The

Treatment of mandibular angle.fractures

245

comparison. The Treatment of mandibular angle.fractures 245 Fig. 1. Immediate postoperative radiograph showing angle

Fig. 1. Immediate postoperative radiograph showing angle fracture treated with transosseous wire fixation and intermaxillary fixation. Wire was inserted through the buccal cortex of the extraction socket.

"gold standard" closed reduction or open reduction using non-rigid fixation has been used for centuries and constitutes such a group. A retrospective study was performed

to gain an appreciation for the complication

of angle frac-

tures in our patient population 49. The records of patients treated by non-ri- gid means of fixation for mandibular angle fractures in a 3-year period were evaluated retrospectively. Treatment of the fractures was by closed reduction and/or open reduc- tion with non-rigid means of interosseous fixation such as transosseous wires, circum- mandibular wires or small positional bone plates (Fig. 1). Postsurgical IMF was pre- scribed for six weeks in all patients. During the 3-year period, 96 patients with 99 fractures through the mandibular angle (three were bilateral) had charts available with sufficient information for inclusion in this studY. Of the 99 fractures, 59 were treated with closed reduction (59%), 34 with open reduction and placement of a transoss- eous wire (34"/0), five with open reduction and a positional bone plate, and one fracture was treated by closed reduction with the ad- dition of a circummandibular wire (1%). All patients were placed into postsurgical IMF for an average of 40 days (range 20 -80 days). Follow-up ranged from 21 252 days with an average of 75 days. Complications developed in 17 fractures (17%), of which there were 13 with infections and four cases where infection was combined with malunion and malocclusion. There were no cases of non-union. The time between ini- tial presentation and surgery in these patients was similar to the overall group of patients. All patients underwent incision and drainage procedures for their infections. Nine patients were hospitalized at least once for their infec- tion and/or malocclusion/malunion. During the incision and drainage procedures, four patients underwent removal of osteosynth- esis; two had teeth in the line of fracture ex- tracted; three patients whose initial treatment was closed reduction had transosseous wires

rate

of traditional

treatment

placed to control the proximal segment; one patient required osteotomy to correct mal- occlusion. Two patients required a second ad- mission; one for incision and drainage, the other for an osteotomy. The results of this study showed that man- dibular angle fractures in this patient popula- tion were associated with a high incidence of postsurgical complications, even when tra- ditional methods of treatment were em- ployed.

Extraoral open reduction and internal fixation using the AO/ASIF reconstruction plate

The AO reconstruction bone plate is a re- inforced plate that is thicker and stronger than the standard AO/ASIF compression bone plate. It comes in various lengths and the plate is three-dimensionally bendable, allowing accurate contouring to the surface of the mandible. The use of three screws on each side of the fracture with this bone pIate is claimed to provide adequate neutralization of functional forces in the absence of coin- pression6~ it is useful in areas of commi- nution, bone loss or obliquity where one can- not use standard compression bone plates. The records of all patients with unilateral fractures of the mandibular angle treated with a reconstruction bone plate over a 3- year period were collected. The technique for application of the plate has been published elsewhere and consisted of an extraoral ap- proach in most instances (Fig. 2)21. The records of fifty-two patients with uni- lateral angle fractures treated in the 3-year period, who had adequate follow-up infor- mation in their chart, were available for re- view. The fractures were categorized as being comminuted in 31 cases, oblique in 12 and simple linear fractures in 9. Following appli- cation of the bone plate,' all fractures ap- peared to be well reduced and stable. All dentulous patients had a reproducible oc- clusion in the operating room. Four patients had pre-existent infections of the fracture

246

El/is

and irrigation drains were placed during surgery in these patients. No other patient had drainage of the wound. Postoperative radiographs taken within the first two days showed excellent reduction in aII cases. There was no radiographic evidence of damage to the inferior alveolar neurovascuIar structures from placement of the fixation hardware. The occlusal relationships were judged as normal in all but four of the dentulous patients at one week following surgery. These four pa- tients had slight occlusal irregularities that required two to three weeks of elastic traction therapy. All four of these patients had con- comitant fractures of the mandible in the tooth-bearing area making it difficult to de- termine which fracture(s) were not perfectly reduced. Follow-up ranged from 9 to 104 weeks with a mean of 18 weeks. All dentulous pa- tients had what was thought to be the nor- mal occlusal relationship for that individual at longest follow-up. Four fractures (7.5%) required further surgical intervention for postsurgical infections. These patients de- veloped acute infections within the first three postsurgical weeks that were refractory to antimicrobial treatment. These patients re- quired hospitalization for extraoral incision and drainage, irrigation through drains, and intravenous "antibiotics". One patient re-

quired plate removal to completely clear the infection.

Lag screws for mandibular angle fractures

al. 46 described

a method of internal fixation of mandibular

angle fractures using a single lag screw. We began to use the lag screw technique in 1988

and found it to be an extremely rapid and

simple method for treating fractures of the mandibular angle. The technique for placing the lag screw has been described in previous publications (Fig. 3) 19,25. Eighty-eight patients that were treated by open reduction and internal fixation of angle fractures by the lag screw technique were in- cluded in this study. Intraoperatively, reduc- tions were judged as excellent in all patients. However, 17 were noted to be unstable to ag- gressive bimanual manipulation of the man- dible. Supplemental methods of fixation were

applied in these cases. In three patients, a 2.0

mm compression bone plate was applied at

the inferior border. In the remaining 14 pa- tients, postoperative IMF was used for vary-

In 1981, NIEDERDELLMANNet

ing periods (3-8 weeks). Follow-up ranged from 6 to 167 weeks, with a mean of 22 weeks. Immediate postoperative radiographic evaluation showed excellent reduction in

every patient except one whose mandibular ramus was slightly flared laterally on the sub- mentovertex view. No treatment was necess- ary, as the facial form was minimally altered. Seven patients were found to have very minor occlusaI discrepancies in the first two post- operative weeks. These were treated satisfac- tory with 3M weeks of intermaxillary elas- tics. No other postsurgical malocclusion re- sulted in any patient. One patient had radiographic evidence of probable impale- ment of the mandibular canal by the screw. Eleven patients developed minor postsurgical soft tissue infections/bone exposures within the first several weeks (no cases of osteomyel- itis occurred). Six resolved on oral anti- microbial treatment without any further in- tervention. Five patients (13%) required further intervention, including removal of the screws and small sequestra. One patient also had extraction of a terminal molar that was thought to be nonvital. Another patient de- veloped non-union and was subsequently bone-grafted.

Intraoral open reduction and internal fixation using two 2.0 mm mini-dynamic compression plates

One AO/ASIF method to neutralize the func- tional forces of an angle fracture is by restor-

the func- tional forces of an angle fracture is by restor- Fig. 2. Immediate postoperative radiograph

Fig. 2. Immediate postoperative radiograph showing infected angle fracture treated with AO reconstruction bone plate. Plate was placed through an extraoral approach. Penrose drain that was inserted dur- ing surgery to help resolve infection can be seen. Drains were only placed if fractures were infected.

Fig. 4. Immediate postoperative radiograph showing angle fracture treated with two 2.0 mm dynamic compression plates.

fracture treated with two 2.0 mm dynamic compression plates. Fig. 3. Immediate postoperative radiograph showing angle

Fig.

3. Immediate postoperative radiograph showing angle fracture

treated with solitary lag screw.

Fig. 5. Immediate postoperative radiograph showing angle fracture treated with two AO/ASIF 2.4 mm compression plates designed for use in mandible.

Treatment of mandibular angle fractures

247

Treatment of mandibular angle fractures 247 Fig. 6. Immediate postoperative radiograph showing angle fracture treated

Fig. 6. Immediate postoperative radiograph showing angle fracture treated with two non-compression miniplates.

Fig. 7. Immediate postoperative radiograph showing angle fracture treated with single non-compression miniplate according to the prin- ciples of CHAMPYet al) 2.

ing the tension and compression trajectories

in the mandible67. The recommended method

pression bone plates specifically designed for

the mandible. The tension band dynamic

talization of bone resulting from the use of compression plates. The hypothesis was put

to restore these trajectories in fractures of the

compression plate employed 2.4 mm screws

forward

that

eliminating

the

use

of

com-

mandibular angle is by the application of two

that

were applied monocortically in locations

pression

might

improve

treatment

results.

bone plates; one at the superior and one at

where bicortical engagement would damage

The

next series of patients with fractures of

the

inferior border of the buccal cortex. Tra-

normal anatomic structures, such as over

the mandibular angle were, therefore, treated

ditionally, the plate at the superior border

tooth roots. The stabilization plate was a

with two 2.0 mm non-compression mini-

was a small compression plate secured with

monocortical screws, whereas the one at the inferior border was a large compression plate, using bicortical screws. The appli- cation of these two bone plates is not difficult through an extraoral approach. However, placement of these plates via an intraoral ap- proach is more demanding due to decreased visibility, making adaptation of the bone plates difficult. Because of the difficulties en- countered in adapting and securing the larger bone plates, the implementation of two 2.0

mm mini-dynamic compression plates was

larger compression bone plate using 2.4 mm

bone screws. Additionally, postsurgical suc-

tion drainage was used in all cases.

Sixty-five consecutive patients with 65 fractures of the mandibular angle were

treated by open reduction and internal fix- ation using two dynamic compression plates placed through a transoral incision with transbuccal trocar instrumentation and 2.4

mm screws (Fig. 5)22. Overall, 21 fractures

(32%) experienced infections requiring sec- ondary surgical intervention. Of the 21 frac-

tures which required plate removal, nine frac-

undertaken in a sample of patients (Fig. 4)2~

tures were healed and required no further

Thirty consecutive patients with 31 frac-

treatment; 12 had no firm bony union and

tures of the mandibular angle that were amenable to compression plate osteosynth-

required postsurgical IME Only one case re- sulted in a malunion with resulting malocclu-

esis

were treated by open reduction and inter-

sion.

nal

fixation using two mini-dynamic com-

pression plates placed through a transoral in- cision with transbuccal trocar instru- mentation. Nine fractures (29%) experienced complications requiring secondary surgical

Intraoral open reduction and internal fixation using two noncompression miniplates

intervention. Three were early infections re-

The

AO/ASIF recommendation for appli-

quiring incision and drainage, removal of the plates and postoperative IME One was a

cation of two compression bone plates for angle fractures was found to result in very

non-union with malocclusion requiring ap-

high

rates of complication in our patient

plication of a more rigid bone plate. Five fractures developed late chronic swelling and low-grade infection requiring plate removal.

population 2~ Because large bony se- questra were frequently encountered in these patients, we thought that a reason for the

Osseous union had occurred in these cases

high

rate of postoperative infection was devi-

and no postoperative IMF was necessary.

plates (Fig. 6). The superior bone plate was applied monocortically, the inferior bone plate bicortically. The technique for appli- cation of the two bone plates has been pub- lished elsewhere23. Sixty-seven consecutive patients with 69 fractures of the mandibular angle were treated by open reduction and internal fix- ation using two non-compression miniplates placed through a transoral incision with transbuccal trocar instrumentation and 2.0

mm self-threading screws. Overall, 19 frac-

tures (28%) experienced complications re- quiring secondary surgical intervention. Most of the complications were postopera-

tive infections requiring surgical drainage

(n=lT) and subsequent plate removal (rl= 16). Of the 17 infected fractures, 11 were healed at the time of plate removal and re- quired no further treatment. Five were still mobile and required a period of IMF for healing. One of the fractures did not heal and

required bone grafting.

Intraoral open reduction and internal fixation using one non-compression miniplate

Because of the high rates of complication re- sulting when two bone plates were placed, it

was decided to attempt the use of a single

Intraoral open reduction and internal fixation using two 2.4 mm mandibular dynamic compression plates

Because of the high rate of postsurgical com- plications in patients treated with two 2.0

mm mini-dynamic compression plates, it was

decided to study the standard AO/ASIF tech-

nique for treating fractures of the mandibu-

lar angle by the application of two com-

Table 1. Comparison of 2.0 mm and 1.3 mm miniplates*

2.0 mm plate

1.3 mm plate

Thickness (mm)

0.9

0.5

In-plane stiffness (N-m 2)

0.007

0.001

Out-of-plane stiffness (N-m 2)

0.158

0.029

In-plane bending strength (N-m 2)

0.14

0.04

Out-of-plane bending strength (N-m 2)

0.93

0.40

* Provided by Synthes USA, Paoli, PA,USA

248

Ellis

Fig. 8. Photograph of standard 2.0 mm miniplate and 1.3 mm mini- plate used in
Fig. 8. Photograph of standard 2.0 mm miniplate and 1.3 mm mini-
plate used in this investigation (A). 1.3 mm plate is extremely thin
and malleable as shown in this photograph (B).

miniplate

CHAMPu et al. 12 (Fig. 7). Eighty-one consecu-

tive dentate patients with non-comminuted fractures of the mandibular angle were treated by intraoral open reduction and internal fixation using a single four-hole miniplate and monocortical screws in a two- year period23i Following application of the bone plate, all fractures appeared to be well reduced and stable. Postoperative radio-

graphs taken within the first two days showed excellent reduction in all cases except four,

where a 2~4 mm gap was noted

ferior border. In spite of this finding on radiographs, immediate occlusal relation- ships were judged as normal in all but one of these patients, who had an slight posterior open bite on the side of the fracture, and re- sponded to light elastic traction for 10 days. Besides this case, two other patients had slight malocclusions that responded to the wearing of elastics for one or two weeks. At the time of arch-bar removal, occlusal re- lationships were judged as normal in all cases. Overall, 13 angle fractures (16%) experi- enced complications requiring secondary sur- gical intervention. Most of the complications (n=ll), however, were minor and could be treated in the outpatient setting. Most com- monly, intraoral incision and drainage and later removal of the bone plate were required.

of

according

to

the

principles

at

the in-

All patients with minor complications had bony union. Only two complications re- quired hospitalization for intravenous anti- microbial treatment and further surgery. One of these patients had a fibrous union, requir- ing a bone graft.

Intraoral open reduction and internal fixation using one malleable non- compression miniplate

The use of a single miniplate for fractures of the angle of the mandible was a simple, re- liable technique with a relatively small num- ber of major complications. However, the question "how much fixation is adequate?" was still not known. LoDD~ 13 has reduced the volume of the original CHAMPYminiplate by half, making them much more malleable, and has not noted any increase in complications when used for mandibular fractures. How much reduction in material is tolerable? The purpose of this last investigation was to pro- spectively evaluate the use of a thin, malle- able miniplate (Synthes Maxillofacial, Paoli, PA, USA) that employs 1.3 mm screws for stabilization of fractures of the mandibular angle. This plate was not designed for use in the mandible, but was designed for use in the non-load bearing regions of the midface (Table 1)(Fig. 8). Patients had a seven-hole strip of the plate secured across the fracture

a seven-hole strip of the plate secured across the fracture Fig. 9. Immediate postoperative radiograph showing

Fig. 9. Immediate postoperative radiograph showing angle fracture treated with single 1.3 mm non-compression plate.

using three monocortical strews on each side

of the fracture. Because of the thinness and malleability of the plates, it was unnecessary to bend the bone plates, allowing the screws to simply coapt the plates to the bone upon tightening. No transbuccal trocar was necess-

ary

for instrumentation. All screws were 5

mm

in length.

Forty-six consecutive patients with 51 fractures of the angle of the mandible were treated by the above method (five were bilat- eral) in a 1.5-year period (Fig. 9)St. Following

application of the bone plate, all fractures

appeared to be well reduced and stable. Post- operative radiographs taken within the first

two days showed excellent reduction in all

cases. Immediate occlusal relationships were judged as normal in all but one patient, whose mandible was shifted to the contra- lateral side in association with moderate swelling of the right submandibular and lat-

eral pharyngeal spaces due to infection of

these spaces present prior to surgery. This re- solved with the resolution of infection and the use of light elastics for 14 days. At the time of arch-bar removal, one patient was judged to have a malocclusion that was attri- buted to malunion at a fracture site other than the angle. All other occlusal relation- ships were judged normal. Seven patients (13.7%) developed compli- cations from their angle fracture postopera- tively, only four (8.7%) required further sur- gical intervention. All complications were considered minor and consisted of plate frac- ture, local infection, or both. Three of the seven patients (42.9%) had asymptomatic fracture of the plate diagnosed on radio- graphs, however there was bony union of the fracture and no intervention was required. Two patients (28.6%) had fracture of the plate with clinical mobility of the fracture

and were placed into IMF for a period of

6 weeks. One of these patients subsequently

developed a localized infection of a devital-

ized tooth in the line of fracture and was

treated with oral antimicrobial drugs and ex- traction of the offending tooth. One patient (14.3%) developed an isolated infection as- sociated with a nonvital tooth that was

Table 2. Treatment for angle fractures

Treatment

(Parkland Memorial Hospital)

Study Reference

Treatment of mandibular angle.fi'actures

249

Sample (no. of angles)

Major Complication~

Non-rigid fixation

PASSE•I et al., 199349

99

17%

AO reconstruction plate (2.7 mm)

ELLIS, 199321

52

7.5%

Solitary lag screw

ELLIS& GHALI,199119

88

13%

Two mini-dynamic compression plates

(2.0 mm)

ELLIS& KARAS,19922o

30

13%

Two mandibular dynamic compression plates (2.4 ram)

ELLIS&

SINN, 199322

65

32%

Two non-compression miniplates (2.0 mm)

E>LIS& WALrCER,199423

67

23%

One non-compression miniplate (2.0 ram)

ELLIS& WALKER,199624

81

2.5%

One malleable non-compr miniplate (1.3 mm)

POTTER& ELLIS, 199951

51

0%

~Major complication refers to the necessityof hospitalization to treat complication

treated by intraoral incision and drainage, extraction of the tooth, and oral "anti- biotics" without plate removal. One patient (14.3%) developed an isolated infection as- sociated with loosening of the.plates several weeks after completing rehabilitation, and was treated with oral "antibiotics" and re- moval of the plate under local anesthesia. No patient developed major complications that required hospitalization or intravenous anti- microbial therapy.

Discussion

In our patient population, treatment of angle fractures with even traditional methods closed reduction and/or non- rigid fixation produced a high rate of complication (17%) 49. This might sur- prise those surgeons from countries where fractures occur in a higher socio- economic group of patients. However, the association of poor oral hygiene, poor dentition, substance abuse and a variety of other factors may predispose this particular sample of patients to postsurgical complications48. The most useful techniques in this patient population were the use of either an extraoral open reduction and internal fixation with the AO/ASIF re- construction plate, or intraoral open re- duction and internal fixation using a single miniplate (Table 2). The use of the reconstruction bone plate was found to result in few complications in a study of angle fractures by IIZUKA& LINDQVIST35. However, the application of this plate is much easier through an extraoral approach that can create its own set of complications. Obviously, we currently employ the latter approach with a 2.0 mm plating system for the vast majority of cases. Every attempt we made at using a two-plate technique via a transoral approach was fraught with high rates of sequestra formation, infection and need for subsequent surgery. We no longer recommend an intraoral two-plate technique.

At the beginning of these investi- gations, we never would have con- sidered using a single miniplate to ad- equately stabilize a fracture of the angle of the mandible without supplemental IME Ten years ago, indoctrinated by the AO/ASIF teaching that absolute ri- gid fixation was necessary, stable methods were deemed necessary and were used in this patient population. Reconstruction plates, lag screws, and two-plate systems were implemented with the thought that they were absol- utely stable methods. However, other than the reconstruction plate, the intra- oral techniques of stable fixation proved either unstable in a certain percentage of cases (solitary lag screw) or fraught with high rates of major postsurgical complications (two plates). The results of these consecutive series of clinical investigations per- formed in our hospital on a similar pa- tient population indicate that, contrary to popular beliefs, up to a point, the in- cidence of major complications after fractures of the mandibular angle are inversely proportional to the rigidity of the fixation applied. Whenever two points of fixation were used for frac- tures of the angle, the complication rate was much higher than when one point of fixation was applied. That is not to say that using a single miniplate does not result in complications. However, the vast majority of problems that arose in patients treated by a single miniplate, such as wound dehiscence, wound infec- tions, plate exposure etc., were easily treated in the outpatient clinic under lo- cal anesthesia. Even removal of the bone plate after healing of the fracture, when necessary, is a simple procedure in the outpatient setting. However, when a second plate was applied at the inferior border, the complications tended to be more severe, with large areas of nonvital bone, sequestra formation and need for plate removal, which were difficult to

treat in the outpatient setting. If one de- fines a complication as an unplanned intervention, the two-plate techniques have a higher complication rate than single plate techniques. However, when one defines a major complication as one that requires hospitalization to treat the problem, the difference between treat- ment techniques becomes much more clear and dramatic in incidence (see Table 2). The finding that a single minipiate outperforms two plates and other more stable forms of fixation defies logic, be- cause conventional wisdom would indi- cate that more stable fixation should provide fewer complications. However, our experience has been the opposite. The use of a single miniplate was as- sociated with much fewer complications than if two plates were used, irrespective of whether the two plates were com- pression or non-compression plates. This seeming dichotomy highlights the limitations of relying on the results of biomechanical bench testing for clinical treatment recommendations. All bio- mechanical tests performed to date in- dicate that two plates are more stable

than one 14,15,18,2a'38,57,58,62. Based upon

these biomechanical studies and clinical results, some investigators have advo- cated the use of two miniplates for frac- tures of the mandibular angle14,15,41,71 LEvY et al. 41 compared a small sample of patients who had fractures of the angle treated with either one or two miniplates without postsurgical IME There were no complications in the 18 patients who had double miniplates, but two complications in the ten pa- tients (20%) who had a single miniplate. Interestingly, another sample of 14 pa- tients with two miniplates plus postsur- gical IMF had a greater rate of compli- cation (7.1%) than when no IMF was used. Our clinical experience is exactly the opposite - a single miniplate worked

250

Ellis

much better than double plating sys- tems. SHIERLEet al. 58 compared a single miniplate to the use of two and found

no significant difference in results. The results of our studies and the one by SCHIRLE et al. 58 indicate that bio- mechanics are only one factor to be considered when treating fractures. There are many others that may be more important. Perhaps improved maintenance of the blood supply to the

bone

one such factor s 7,17,32. We, therefore,

agree with EWERS & HARLE26'27 who questioned the need for absolute rigid-

ity for treatment of fractures. From the foregoing, it is obvious that fractures of the mandibular angle do not require the amount of stability as determined in biomechanical tests. This should not be

surprising

TATE et al. 69

which showed that bite forces are sub- normal for many weeks after fracture of the mandible. What has yet to be determined is exactly what are the requirements for fixation of angle fractures. Based upon the results of using a malleable 1.3 mm plating system, this plate should not be routinely used for such fractures be- cause some fractured during function. However, the fact that most did not fracture indicates that the 2.0 mm mini- plates are probably over-engineered for this task. Perhaps a thinned down ver- sion of the 2.0 mm miniplate system will prove even simpler to apply and ad- equately stable without plate fracture. Another alternative might be to thicken the 1.3 mm plate. These results also in- dicate that biodegradable fixation sys- tems, which do not have the same strength as metallic plates of the same dimension, may provide adequate fix- ation in this region. There have been studies on the treat- ment of fractures of the mandible that have shown that operator experience is an important factor in treatment re- sults 3'34'37. There is no question that ex- perienced surgeons can treat injuries faster and perhaps with less surgical trauma that those who are less experi- enced. Because the techniques that proved most beneficial were those com- pleted latest in this 10-year experience, one might argue that the improved re- sults are not due to treatment methods but instead due to operator experience, which one would presume to increase over time. There is one factor that re- futes this supposition, however. A var-

by GERLACH et al. 3~ and

because

of

limited

dissection

is

in light of bite force studies

iety of residents were involved with the operative procedures over the 10-year pcriod. The experience level of the resi- dents was similar because they rotated to the treating hospital for the same duration during their training pro- grams. The only individual present over the entire 10 years was the faculty sur- geon, who merely directed and assisted during the surgery. At least one other study has also demonstrated that single plates perform as well as when two are used 58. A more important consideration about operator experience, however, is that it takes much less experience to be- come adept at using a single miniplate than the other techniques. Application of a single miniplate takes only a few minutes and can be taught very quickly to a trainee. Placement of the second plate at the inferior border is a more difficult task and requires more experi- ence to become facile. Placement of a solitary lag screw is also technique sen- sitive. Fortunately, the technique that offers the best results is also that which is the simplest to learn. The use of a single miniplate was not in keeping with the original AO/ASIF principles. Historically, the four AO/ ASIF principles for treating skeletal fractures were: 1) anatomic reduction; 2) rigid fixation; 3) atraumatic surgical technique; and 4) immediate active function, in 1994, the AO/ASIE for the first time in its history, changed the sec- ond principle to "functionally stable fixation", rather than rigid fixation. This change arose out of orthopedic surgery, where intramedullary nails and other less "rigid" forms of fixation were proven to be "functionally" stable. The ability of a single miniplate applied at the superior border of the mandible to "neutralize" functional forces and allow immediate active mobility is finally rec- ognized by the AO/ASIF as a reliable means of providing functional stability of the fracture. The above relates the experience of one hospital, with one patient popula- tion, treated by a large group of resi- dents with one faculty member. Whether or not the results are repeat- able at other institutions is unknown. Scientifically, the question about which technique offers the best result will require a randomized prospective study. This type of a study will allow factors such as operator experience, patient population and the multitude of other uncontrolled factors to be less

likely to affect the outcome.

study has not yet been performed but

is currently underway in the United States.

Such a

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Address:

Edward Ellis 11I, D.D.S., M.S. Professor, Oral and Maxillofacial

Surgery

The University of Texas Southwestern

Medical Center 5323 Harry Hines Blvd. CS3.104 Dallas, Texas 75235 9109 USA Tel." +1 214 648 8963 Fax: +1 214 648 7620 e-mail: eellis@mednet.swmed.edu