Improper reduction and fixation of bilateral anterior mandibular fractures: a case report

Conservative management of pediatric mandibular distal fractures-A retrospective study

BACKGROUND/AIM

Pediatric mandibular distal fractures present unique treatment challenges which are usually managed with open reduction and internal fixation (ORIF) with the risk of developing tooth bud injuries. Conservative management through maxillomandibular fixation (MMF) with orthodontic bracket-elastic as an out-patient department (OPD) service has been used for these fractures presenting with derangement of occlusion. The aim of this study was to retrospectively analyze MMF with orthodontic bracket-elastic as a treatment method and its outcome for management of pediatric mandibular distal fractures.

METHODOLOGY

Data of seventeen pediatric cases diagnosed with displaced mandibular distal fractures managed with MMF with orthodontic bracket-elastic over a period of 5 years were analyzed. In this technique, two weeks of immobilization and one week for guiding elastics were used.

RESULTS

The mean age of patients was 7.6 ± 1.6 years with a mean follow-up of 24 months. All fractures healed uneventfully with satisfactory occlusion. The cases included 23.5% minimally displaced, and 64.7% moderately displaced and 11.8% significantly displaced fractures with step deformity with successful remodeling of the lower border contours over a duration of 18 months ± 1 month. The developing tooth buds in the fracture line showed no complications except for root dilacerations/malformation (n = 3).

CONCLUSION

MMF with orthodontic bracket-elastic is a viable and conservative technique for the management of pediatric mandibular distal fractures which need to be verified through randomized trials for generalization of the results.

Fixation of mandibular angle fractures: clinical studies

PURPOSE

The purpose of this study was to review the literature regarding the evolution of current thoughts on fixation of mandibular angle fractures (MAFs).

METHODS

An electronic search in PubMed was undertaken in August 2012. The titles and abstracts from these results were read to identify studies within the selection criteria. Eligibility criteria included studies from the last 30 years (from 1983 onwards) reporting clinical studies of MAFs.

RESULTS

The search strategy initially identified 767 studies. The references from 1983 onwards totaled 727 articles. Fifty-four studies were identified without repetition within the selection criteria. Two articles showing significance in the development of treatment techniques were included. Additional hand-searching yielded 13 additional papers. Thus, a total of 69 studies were included.

CONCLUSIONS

Prospective randomized controlled studies of MAFs repair techniques are scarce. The available data at best predict that complications are associated with all kinds of fixation techniques. The similar results of complications in studies using different methods of fixation indicate that biomechanics are only one factor to be considered when treating MAFs. A second fracture in the mandible (which was observed in the majority of the studies' population) can confound the outcome data because the fixation requirements of a double fracture are often different from those for an isolated fracture. It can be necessary additional effort intended for increase of stability when using biodegradable plate system to fixate MAFs. The use of 1.3 mm malleable miniplates was associated with an unacceptable incidence of plate fracture, suggesting that this is not the most adequate system to treat MAFs. The use of the 3D grid plates has shown good clinical results. The efficiency of locking miniplate system is yet to be proven because there are few clinical studies with its use to fixate MAFs, although they have shown good results. When considering the use of semirigid or rigid fixation systems, the use of two miniplates outweigh the advantages of the use of one reconstruction plate, although the use of miniplates is not recommended for displaced comminuted MAFs. Although it has been shown that absolute rigid fixation is not necessary for fracture healing, any system that provides superior stability without impacting negatively on other aspects of the procedure, i.e., time, exposure, and cost, should be favored. MAFs can be treated in a highly effective way and with a relatively low rate of complications with monocortical miniplate fixation. The large number of studies on the treatment of MAF reflects the fact that a consensus has not been reached for a single, ideal treatment method.

Fixation of mandibular angle fractures: in vitro biomechanical assessments and computer-based studies

PURPOSE

The purpose of this study was to review the literature regarding the evolution of current thoughts on fixation of mandibular angle fractures (MAFs), based on in vitro biomechanical assessments and computer-based studies.

METHODS

An electronic search in PubMed was undertaken in August 2012. The titles and abstracts from these results were read to identify studies within the selection criteria. Eligibility criteria included studies from the last 30 years (from 1983 onwards).

RESULTS

The search strategy initially identified 767 studies. Thirty-one studies were identified without repetition within the selection criteria. Two articles showing significance in the development of treatment techniques was included. Additional hand searching yielded five additional papers. Thus, a total of 38 studies were included.

CONCLUSIONS

The osteosynthesis positions as well as the plating technique play important roles in the stability of MAF repair. The only in vitro study evaluating the use of wire osteosynthesis concluded that wires placed through the lower border approach would provide greater stability than those at the upper border. Many studies indicate that the use of two miniplates avoids (or decreases) lateral displacement of the lower mandibular border and opening of the inferior fracture gap. Some studies even suggest that the use of two miniplates may be considered a more "rigid" fixation technique for MAFs than the use of a reconstruction plate. When using two miniplates, the biplanar plate orientation provides greater biomechanical stability than the monoplanar one. However, despite its greater biomechanical stability, the two-miniplate technique has some disadvantages that should also be taken into account. Studies with biodegradable plates suggest the use of at least two plates for each MAF. There are few studies with compression plates, and they have not yet reached a consensus. The solitary lag screw proved to withstand the functional loading of the mandible; however, only few biomechanical assessments were performed. In vitro studies have shown good biomechanical stability with the use of 3-D grid plates. The use of malleable miniplates alone is not sufficient to withstand the early postoperative bite force. Some studies suggest that the segment of the tension band miniplate located at the distal fragment of the MAF should be fixed with three screws. The studies also showed some limitations. None considered the stabilization of the fracture site afforded by the masseter-pterygoid muscle pouch. Most of the studies did not evaluate plating system strength in the long term and therefore did not observe the effect of resorption on the strength of the different biodegradable plating systems. Another limitation of many studies is the absence of a control group. 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.