Comparison of intraoral and extraoral approaches to mandibular angle fracture repair with cost implications

Infection Rates of an Intraoral Versus Extraoral Approach to Mandibular Fracture Repairs are Equal: A Systematic Review and Meta-Analysis

PURPOSE

This study investigates whether the intraoral approach to mandibular open reduction and internal fixation, through exposure to the oral cavity's microbiome, results in higher infection rates compared to the extraoral approach, thus addressing a critical public health concern, potentially offering an opportunity to reduce health-care costs, and aiming to guide effective clinical practice.

METHODS

In this systematic review with meta-analyses, a review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A comprehensive literature search was conducted using Embase and PubMed for articles published between 1989 and 2023. Inclusion criteria targeted studies on open reduction and internal fixation mandibular fractures comparing intraoral and extraoral approaches and reporting infection rates. Exclusion criteria eliminated non-English articles, case reports, and studies with insufficient approach-specific data. The primary outcome was the postoperative infection rate, with surgical approach as the predictor. Covariates such as age, sex, diabetes, and smoking status were included when reported. Data were analyzed using R software, employing random-effects models due to anticipated heterogeneity (I2 statistics).

RESULTS

From 61 studies, 11 provided direct comparisons involving 1,317 patients-937 intraoral and 380 extraoral. Infection rates were 5.9% for intraoral and 10% for extraoral approaches. Pooled relative risk was 0.94 [95% confidence interval, 0.63, 1.39], suggesting no significant risk difference. Prevalence of infections was estimated at 9% for intraoral and 6.1% for extraoral procedures, with significant heterogeneity (I2 = 84% for intraoral and 56% for extraoral).

CONCLUSION

Our meta-analysis found no significant difference in infection rates between the two approaches. There is opportunity to expand on reporting complication rates comparing the various approaches to mandibular fixation. Until these data are presented, surgeon preference may dictate the operative approach to expose the mandible for reduction and fixation.

Management of Mandibular Angle Fractures Using Single Y-Shaped Titanium Miniplate at the Superior Border: A Prospective Clinical Study

Treatment of angle fractures remains controversial. The various techniques documented for the treatment are: wire osteosynthesis, one miniplate at superior border (2.0 mm), a single plate on inferior border (2.3 or 2.7 mm) along with tension band in the form of arch bar at the upper border, 2 miniplates (1 at superior border and 1 at inferior border), 3-D strut plates or lag screw. To evaluate the efficacy of single Y-shaped titanium miniplate at the superior border in the management of mandibular angle fractures. Total of 15 healthy adult patients reporting to the department of Oral and Maxillofacial Surgery for the treatment of mandibular angle fractures was randomly selected. All the cases were assessed clinically at 1st post-operative day, 1st, 3rd, 6th and 12th week post-operatively for pain, status of occlusion, neurosensory deficit and postoperative hard & soft tissue healing. Radiographic assessment was also done at 1st postoperative day, 6 weeks and 12 weeks. Postoperative pain, infection, wound dehiscence, neurosensory deficit were not evident during the follow- up periods. Radiographically, the fracture reduction was good and plate fracture was not seen in any case. Y- shaped titanium miniplate is an effective method in the management of the mandibular angle fractures and provided satisfactory results.

Medial Epicanthoplasty With the Classic and Modified Skin Redraping Method: A Retrospective Case Control Study

ABSTRACT

The skin redraping method for medial epicanthoplasty is characterized by some shortcomings which warrants modification. In this study, clinical data of 193 patients who underwent medial epichanthoplasty by the modified skin redraping technique or the classic skin redraping technique were reviewed retrospectively. The patients underwent operation between May 2018 and June 2020 and were followed up for not less than 6 months. Interepicanthal distance , interpupillary distance, patient satisfaction, and postoperative complications were evaluated. In terms of interepicanthal distance/interpupillary distance ratio (P > 0.05) and satisfaction score (P = 0.759), the modified skin redraping technique and the classic skin redraping technique were similar. In the classic skin redraping group, there were 3 cases of visible scarring in the lower eyelid, corresponding to significantly more cases than in the modified skin redraping group (n = 0, P < 0.001). There were more out-fold cases in the modified skin redraping group (76/90) than in the classic skin redraping group (17/88) (P < 0.001). Utilizing the modified skin redraping medial epicanthoplasty can prevent medial hooding of the upper eyelid, reduce the probability of visible scarring, and produce more out-fold with concurrent double eyelidplasty compared with classic skin redraping epicanthoplasty.Level of evidence: IV.

Management of Mandible Angle Fractures With a Right Angle Drill: Description of Technique

ABSTRACT

Management of mandible angle fractures can be challenging within the confines of the oral cavity where the use of linear instruments may result in structural weakness or malalignment secondary to improper placement. A right angle drill can facilitate a more ergonomic approach, with direct perpendicular placement of the instrument over the angle fracture. In addition, local soft tissue strain is minimized, and the need for a transcutaneous exposure can be avoided for additional plate placement. The right angle drill technique is simple, reproducible, and can be easily incorporated into routine mandible angle fracture management.

Experimental validation of finite element simulation of a new custom-designed fixation plate to treat mandibular angle fracture

BACKGROUND

The objective of the study was to validate biomechanical characteristics of a 3D-printed, novel-designated fixation plate for treating mandibular angle fracture, and compare it with two commonly used fixation plates by finite element (FE) simulations and experimental testing.

METHODS

A 3D virtual mandible was created from a patient's CT images as the master model. A custom-designed plate and two commonly used fixation plates were reconstructed onto the master model for FE simulations. Modeling of angle fracture, simulation of muscles of mastication, and defining of boundary conditions were integrated into the theoretical model. Strain levels during different loading conditions were analyzed using a finite element method (FEM). For mechanical test design, samples of the virtual mandible with angle fracture and the custom-designed fixation plates were printed using selective laser sintering (SLS) and selective laser melting (SLM) printing methods. Experimental data were collected from a testing platform with attached strain gauges to the mandible and the plates at different 10 locations during mechanical tests. Simulation of muscle forces and temporomandibular joint conditions were built into the physical models to improve the accuracy of clinical conditions. The experimental vs the theoretical data collected at the 10 locations were compared, and the correlation coefficient was calculated.

RESULTS

The results show that use of the novel-designated fixation plate has significant mechanical advantages compared to the two commonly used fixation plates. The results of measured strains at each location show a very high correlation between the physical model and the virtual mandible of their biomechanical behaviors under simulated occlusal loading conditions when treating angle fracture of the mandible.

CONCLUSIONS

Based on the results from our study, we validate the accuracy of our computational model which allows us to use it for future clinical applications under more sophisticated biomechanical simulations and testing.

The Healthcare Cost of Mandibular Nonunions

The aim of this retrospective cohort study was to compare the costs and characteristics between isolated mandible fractures and mandibular nonunions. From October 2015 to December 2016, the National Inpatient Sample (NIS) was searched for patients admitted with a primary diagnosis of a mandible fracture. The sample was divided between those admitted for an initial evaluation of an isolated fracture and a fracture nonunion. Demographic descriptors, injury characteristics, and inpatient factors were recorded. A total of 1432 patients were included in the final sample, of whom 51 (3.6%) were admitted for a nonunion. Nonunion patients were significantly older (P < 0.01), and nonunions were more often localized to the body (24 vs 11%; P = 0.02). Compared to that of isolated fractures, a greater proportion of nonunions required open reduction and internal fixation (86 vs 59%; P < 0.01) and bone grafting (37 vs 1.4%; P < 0.01), and nonunions imparted +32.6% greater hospitals costs (median: $10,680 vs 14,162; P < 0.01). In conclusion, compared to isolated mandible fractures, mandibular nonunions occurred in older patients, had a higher frequency in body of the mandible, and utilized significantly more hospital resources per admission.

Mandibular angle fractures: a comparative study between one- and two-plate fixation

BACKGROUND/AIM

The mandibular angle fracture is a challenging fracture to manage. Over time, the literature has shown many types of treatment modalities and different kinds of internal fixation. The aim of this study was to evaluate the outcomes and complications of mandibular angle fractures managed by Champy's technique and two-plate fixation, over a period of 20 years.

MATERIAL AND METHODS

The files of 149 patients with 155 angle fractures fulfilled the inclusion criteria and were chosen for this study. Data were collected regarding gender, age, race, date of trauma, addictions, etiology, signs and symptoms, fracture management, and complications.

RESULTS

Prevalence was higher in males (82%), Caucasians (62%), and during the third decade of life (62%). Mean age was 26.5 years. The main cause was interpersonal violence, and the mean follow-up period was 232 days. The main signs and symptoms were pain, edema, and mouth-opening restriction. The most often associated fracture involved the mandibular condyle, and the most common complication was infection.

CONCLUSION

There was no difference between the two modalities of treatment. However, the one-plate fixation technique had fewer complications.