Complications of miniplate osteosynthesis for mandibular fractures

Compositional and surface changes of retrieved stainless-steel hardware and its effects on surrounding soft tissues: A prospective study

Purpose

To evaluate the surface, compositional, and histological changes in the overlying soft tissues of retrieved stainless-steel mini-plates and screws used for rigid internal fixation in the maxillofacial skeleton.

Materials and Method

A prospective study was conducted comprising 60 patients who sustained maxillofacial trauma and underwent ORIF in our unit previously and who required hardware retrieval in the post-operative phase. The retrieved hardware was evaluated for surface and compositional changes with the help of a scanning electron microscope for surface roughness and corrosion changes. Energy-dispersive X-ray study was done to know the composition and metal release from the hardware. The data obtained from these results were compared with a control unused and a sterile stainless-steel mini-plate and screw. The effects of the corrosion changes of this hardware on the adjacent soft tissues were evaluated histologically to assess the cellular changes of the soft tissue cover overlying the stainless-steel mini-plates and screws.

Results

A total of 96 stainless-steel mini-plates and 380 stainless-steel screws were retrieved from 60 patients. The control plate was smooth without any surface and corrosion defects, while the retrieved mini-plates irrespective of the reason for removal have shown surface roughness. Fe and Ni ions were found to be significantly reduced in the retrieved mini-plates. The presence of CrC in the retrieved plates indicates corrosion, which was seen only in hardware retrieved from symptomatic patients. The histological study revealed chronic inflammatory cell infiltrate with hyalinized connective tissue in all the samples irrespective of the reason for the removal of the plate.

Conclusion

Stainless-steel mini-plates and screws act as a potent foreign body material and initiate a localized inflammatory reaction due to its corrosive products with longer duration of stay. Hence, the authors advocate the overall shift in the use of stainless-steel hardware to titanium hardware for ORIF.

Prevalence of Frey syndrome following extraoral surgical treatment for mandibular fractures: a systematic review and meta-analysis

Our study aims to estimate the prevalence of Frey syndrome following open reduction and internal fixation (ORIF) for mandibular fractures. Two reviewers independently conducted a systematic literature search in the Medline and Scopus databases. The pooled prevalence with 95% confidence intervals (CI) was estimated, and quality assessment, outlier analysis, and influential analysis were performed. In total, fifteen eligible studies were included in this meta-analysis. One study was identified as critically influential. The overall prevalence of Frey syndrome following extraoral surgical treatment for mandibular fractures was estimated as 0.01% (95%CI 0%-0.7%) with moderate heterogeneity observed between studies. In the meta-regression analysis with continuous variables, no statistically significant association was observed. Despite the relatively low prevalence, the impact of Frey syndrome on affected individuals should not be underestimated. Additional research will provide a more comprehensive understanding of the underlying factors contributing to Frey syndrome, leading to improved preventive measures and treatment strategies. A better grasp of the prevalence and associated risk factors will aid in the development of guidelines to minimize the occurrence of this syndrome.

The Use of Combined Microplate And Miniplate in the Fixation of the Mandibular Fractures (A Randomized Clinical Trial)

The study group patients have been treated with 1.6 microplates at the superior border and 2.0 miniplate at the inferior border to evaluate its efficacy in the fixation of symphyseal and parasymphyseal fractures using this technique. The control patients were treated with two 2.0 plates. The stability was assessed using computed tomography immediately performed postoperatively and after 6 months. Assessment of the change in the intercanine distance using the Student T test was statistically Non Significant ( P value 0.34). The change of intercanine distance in the study was 0.04 ± 0.05 mm, compared with that of the control, which was 0.01 ± 0.03 mm. Assessment of change in intermental foramina distance was statistically NS ( P value = 0.06). The average difference in intermental foramina distance in the study was 0.04 ± 0.05 mm, compared with the control, which was 0.002 ± 0.004 mm. Based on the findings of the current study, the authors recommend the use of microplates combined with miniplates in the correction of both symphyseal and parasymphyseal fractures successfully.

Prevalence of surgical site infections after open reduction and internal fixation for mandibular fractures: a systematic review and meta-analysis

Our study aims to estimate the prevalence of surgical site infections (SSI) following open reduction and internal fixation (ORIF) for mandibular fractures and to determine the effect of potential moderators on it. A systematic literature search (Medline and Scopus databases) was conducted independently by two reviewers. The pooled prevalence with 95% confidence intervals was estimated. Quality assessment as well as outlier and influential analysis were performed. Additionally, subgroup and meta-regression analysis were conducted in order the effect of categorical and continuous variables on the estimated prevalence to be investigated. In total, seventy-five eligible studies (comprising a sum of 5825 participants) were included in this meta-analysis. The overall prevalence of SSI following ORIF for mandibular fractures was estimated as high as 4.2% (95% CI 3.0-5.6%) with significant heterogeneity between studies. One study was identified to be critically influential. In the subgroup analysis, the prevalence was 4.2% (95% CI 2.2-6.6%) among studies conducted in Europe, 4.3% (95% CI 3.1-5.6%) among studies conducted in Asia and higher among those conducted in America (7.3%) (95% CI 4.7-10.3%). It is important for healthcare professionals to be aware of the etiology of these infections, despite the relatively low rate of SSI in these procedures. However, further, well-designed prospective and retrospective studies need to be conducted in order this issue to be fully clarified.

Significance of Microbial Analysis during Removal of Miniplates at Infected Sites in the Craniomaxillofacial Region - An Evaluative Study

Introduction:

Open reduction and internal fixation (ORIF) can be complicated by miniplate exposure, loosening, or infection. Infected miniplates lead to exposure, extrusion, fistula formation, bony nonunion, and osteomyelitis. Whenever any posttreated cases of ORIF become infected, it is treated blindly with a high dose of antibiotics and surgical removal of infected miniplates or screws. The aim and objectives of the study were to identify the frequency and site of infection in craniomaxillofacial implants and significance of microbes isolated from the infected region.

Materials and Methods:

Removal of miniplates was being performed on 19 patients. Among them, 14 had infection or sinus opening, 3 had plate exposure, and 2 were removed asymptomatically according to patient willingness. Aspirated fluid/pus was collected and sent for microbial culture and sensitivity test. Test of significance of individual microbes was done using Z-test and the value of P was calculated.

Results:

Among 14 patients associated with miniplate infection, 11 (78%) had infection in the mandible and 3 at zygoma. The bacteria isolated were mainly Staphylococcus aureus (7) along with coagulase-negative Staphylococcus (2), Pseudomonas aeruginosa (3), Escherichia coli (2), Streptococcus salivarius (2), and Acinetobacter genre (1). S. aureus was predominantly present in majority of the samples and statistically significant at P = 0.023.

Discussion:

The present study observed that in contrast to other sites in the body, there is versatility in microbial flora in the craniomaxillofacial region. It is essential for routine microbial analysis of samples and antibiotic susceptibility test for proper treatment of such cases.

Comparative Evaluation of 3d Locking Versus Non-Locking Titanium Miniplates in the Treatment of Mandibular Fracture

The introduction of 3-dimension systems for the treatment of mandibular fractures and continuity has offered certain advantages over other plating system. The present study was undertaken to compare 2.0 mm 3D titanium locking and non-locking miniplates in the management of mandibular fractures. A prospective study was conducted on 40 patients (20 in each group) of mandibular fractures treated by open reduction and internal fixation. Group A patients underwent osteosynthesis using 2.0 mm 3-D titanium locking miniplates while Group B used non-locking miniplates. Subsequent follow-up was assessed for pain, swelling, infection, paresthesia, malocclusion, mobility between fracture fragments and hardware failure in these patients. Functional occlusion was achieved postoperatively in all the patients. At 12 weeks of the time intervals, significant pain was observed in group B. At 1 week interval, 6 (30%) patients in both groups reported with swelling. Only one (10%) patient in each group had paresthesia which got resolved gradually over a period of 3 months. Infection was observed in only 2 (10%) patient in Group B at 3 months. Only 2 (10%) patient in Group B had hardware failure at 3 months interval. Statistically, there was no significant difference between both the groups at any time interval (p > 0.05). 3D titanium locking miniplates are effective in the treatment of mandibular fractures with lesser overall complications as compared to non-locking miniplates.

The Implications of Titanium Alloys Applied in Maxillofacial Osteosynthesis

Titanium alloys are known for their biological, mechanical and chemical properties, which have successfully expanded their use in the maxillofacial field. The internal fixation using titanium miniplates and screws offer a new perspective for the treatment of trauma and in orthognathic surgery and maxillofacial oncology. Although, titanium is highly recommended for its excellent biocompatibility, recent research has focused on identifying the potential local and general implications of the interactions between the human tissue and the metallic particles. This present review aims to outline the existing tissue changes, cellular alterations and future perspectives regarding the use of titanium-based alloys as osteosynthesis materials, taking into consideration the existing present debate whether the routinely removal of these materials should be an indication.

Evaluation of two internal fixation techniques for mandibular parasymphyseal fractures comparing conventional titanium miniplates with customised titanium CRB omega miniplates: a prospective study

Our aim was to compare the efficacy and outcome of customised, titanium, CRB (Chandrashekhar Rushiji Bande), omega miniplates with those of conventional titanium miniplates in the management of parasymphyseal fractures of the mandible, with or without involvement of the mental nerve, after clinical and radiographic evaluation. A total of 252 parasymphyseal fractures in 200 patients were selected for the study over the period of seven years (January 2010-January2017) and divided randomly into two groups. The first group included 126 fractures treated with two conventional titanium miniplates (conventional group) and the second 126 fractures treated with one customised, titanium, CRB, omega miniplate (customised group). All operations were done by the same surgeon. Duration of operation (from placement of incision to closure of the defect) was recorded. Postoperative paraesthesia, infection, and acceptability of the plate to patients were also recorded. Postoperative healing was evaluated radiologically at one week and six months postoperatively. Operations were significantly shorter, and significantly fewer patients developed paraesthesia or infection, in the customised group. These patients were also happier with their miniplates, and had good radiological bony healing. In conclusion, a single customised, titanium, CRB, omega miniplate is an effective and economical alternative to two conventional titanium miniplates in the management of parasymphysis fractures of the mandible.

Treatment Delay Impact on Open Reduction Internal Fixation of Mandibular Fractures: A Systematic Review

BACKGROUND

The impact of mandible fracture treatment delay has been contested in the literature for decades, with conventional wisdom favoring earlier surgical treatment to prevent postoperative complications, primarily infection. Through a systematic review of all available evidence, this study aims to determine whether delay to open reduction and internal fixation of traumatic mandibular fractures influences outcomes.

METHODS

MEDLINE, EMBASE, CINAHL, and Web of Science were systematically searched for English language literature pertaining to the above research question and screened in duplicate. Methodological quality scoring was performed using MINORS criteria. Qualitative and quantitative findings from relevant studies are presented.

RESULTS

Twenty eligible studies including 2,671 patients had open reduction internal fixation, with or without adjunct mandibulomaxillary fixation. All studies were observational cohort or case-control studies of low methodological quality with a mean MINORS score of 6.5 of 16 (40.6%) for noncomparative studies and 11.2 of 24 (46.7%) for comparative studies. Only 5 of 20 (25%) studies recommended earlier treatment. Due to insufficient reporting of data and study heterogeneity, the impact of treatment delay on complications could not be quantitatively analyzed.

CONCLUSIONS

There is substantial heterogeneity and no consensus on the definition of "early" versus "delayed" surgical treatment for patients with traumatic mandibular fractures. The majority of included studies do not make a recommendation for earlier treatment. Future, well-designed prospective studies are essential to determine if there is an optimal surgical treatment delay of mandibular fractures that mitigates the risk of infectious and noninfectious complications.

Bioabsorbable plates versus metal miniplate systems for use in endoscope-assisted open reduction and internal fixation of mandibular subcondylar fractures

PURPOSE

To compare bioabsorbable plates with metal miniplate systems for use in endoscope-assisted open reduction and internal fixation (EAORIF) of mandibular subcondylar fractures.

MATERIALS AND METHODS

This retrospective cohort study included patients with mandibular subcondylar fractures treated with EAORIF using bioabsorbable unsintered hydroxyapatite/poly l-lactide composite plates or titanium miniplate systems. The outcome variables included preoperative fracture conditions, postoperative stability during fracture healing, and complications during the follow-up period. Other variables included clinical characteristics (age, sex, fracture site, and total follow-up duration) and intra- and postoperative data (surgical duration, duration of intermaxillary fixation/elastic band guidance). Variables were evaluated using descriptive statistics and compared between groups using the Mann-Whitney test and the chi-square test or Fisher's exact test, as appropriate.

RESULTS

In total, 28 patients were analyzed, including 13 who underwent EAORIF using bioabsorbable plates and 15 who underwent EAORIF using titanium miniplates. With the exception of second surgery for plate removal, none of the assessed variables showed significant differences between the two groups (p < 0.05).

CONCLUSIONS

Our results suggest that EAORIF using biodegradable plates is a stable and reliable method for the management of mandibular subcondylar fractures and eliminates the need for secondary surgery for plate removal.

Is the Three-Dimensional Strut Plate an Adequate Fixation Technique for Mandibular Symphysis Fractures?

PURPOSE

We present a series of cases of mandibular symphysis fractures treated at our institution with a 3-dimensional strut plate. The aim of the present study was to confirm the stability of this fixation technique and discuss its advantages, disadvantages, and potential complications.

PATIENTS AND METHODS

We designed and implemented a retrospective cohort study of patients who underwent surgery by the same surgeon at our institution from July 2012 to April 2014 for a mandible fracture with a symphysis component. The patients were evaluated to identify aspects of occlusion, fracture mobility, postoperative infection, and the need for hardware removal.

RESULTS

The sample included 12 subjects who had met the inclusion criteria. The inclusion criteria were a linear noncomminuted fracture, sufficient distance from the mental foramina, a maximum of 5 days between the trauma and surgery, and a minimum postoperative period of 3 months. The mean age of the sample was 33.4 years, and 1 of the 12 patients (8.3%) was female. Of the 12 patients, 10 did well, and 2 developed a surgical site infection, 1 of whom also experienced nonunion and required additional fixation.

CONCLUSIONS

The results of the present study suggest a 3-dimensional strut plate applied to symphysis fractures provides adequate fracture stabilization with a risk of complications comparable to that of more traditional fixation methods. In addition, the technique has the added advantage of minimal manipulation and adaptation, which could shorten the overall operating time.

Transoral approach alone in single miniplate osteosynthesis of angle fracture - our experience

Aim:

The aim of this study was to determine the outcome of transoral approach alone to treat the mandibular angle fracture using single 2.0 mm miniplate.

Materials and Methods:

In this study, 28 patients were included and treated with 2.0 mm single miniplate osteosynthesis at upper border along Champy's line of osteosynthesis using transoral approach alone.

Results:

All the cases were treated successfully with 2.0 mm single miniplate with common complications such as infection (two cases) and plate exposure (one case) in a total of two cases.

Conclusion:

Use of single miniplates by transoral approach alone for superior border osteosynthesis is effective and simple approach without need of extra armamentarium.

Comparative evaluation of bite force analytical study following mandibular osteosysthesis using three-dimensional and conventional locking miniplates

AIMS AND OBJECTIVES

The aim is to study the effectiveness of 2 mm three-dimensional (3D) titanium miniplates and 2 mm conventional titanium miniplates in osteosynthesis of mandibular fractures by comparing the change in bite force.

METHODOLOGY

The study comprised forty patients of age group 20-40 years, weighing 55-75 kg having mandibular fractures. Patients were randomly divided into two equal groups In Group A, twenty patients underwent osteosynthesis using 3D titanium miniplates (2.0 mm system), whereas in Group B, twenty patients underwent osteosynthesis using conventional titanium miniplates (2.0 mm system). After fixation of fracture segments with miniplates, the patients were assessed on the basis of evaluation of bite force at incisor, right molar and left molar region after 1, 3, 6 , and 8 weeks. Comparison of change in bite force was done between Group A and Group B at different follow-ups at incisor, right molar, and left molar.

RESULTS

Bite force recordings showed increasing values at subsequent follow-ups, corresponding to the healing of the fracture in both groups. At follow-up III (6 weeks) and IV (8 weeks), bite force values reached near to those in healthy individuals. A significant difference was observed in change in bite force of Group A and Group B at incisor left molar and right molar on subsequent followups. 3D titanium miniplate requires less surgical exposure of the underlying fracture site, with a minimal traction of the surrounding soft tissue.

INTERPRETATION AND CONCLUSION

3D miniplates in mandibular fractures are efficacious enough to bear masticatory loads during the osteosynthesis of fractures. It gives the advantage of greater stability, increased bite force, reduced implant material, and 3D stability.

Reconstruction of tooth-bearing portion of mandible using polyglactin 910 sutures for internal fixation in the third-world: functional and cosmetic outcome

BACKGROUND

This study analyzed the cosmetic and functional outcome of cases involving reconstruction of tooth-bearing portion of the lower jaw, using a polyglactin 910 suture for fixation.

PATIENTS AND METHOD

This prospective intervention study documented the treatment outcome in 25 consecutive adult patients, who underwent immediate mandibular reconstruction following segmental resection of tooth-bearing portion of mandible. Cortico-cancellous bone graft was taken from the inner table of iliac bone, sparing the crest. Use of post-surgical inter-maxillary fixation was avoided.

RESULTS

Twenty-five patients were recruited for the study. Seventeen were males and eight were females. Their ages ranged from 18 to 50 years, with a mean of 30.0 years. Average length of grafted bone was 9.8 cm. Following surgery, all 25 (100%) patients were judged to have satisfactory facial symmetry. One (4.0 %) had altered dental occlusion. Twenty-five (100%) had satisfactory bone union. All of the patients claimed to masticate satisfactorily. Assessment was carried out at the last post-operative follow-up visit for each patient who ranged between 22 and 83 months.

CONCLUSION

Use of polyglactin 910 suture material for fixation in mandibular reconstruction following segmental resection of tooth-bearing portion has proven to be a cosmetic and functional success. It may serve as alternative for those among whom conventional treatment methods may be contraindicated. This method of bone fixation may serve as a reliable and much cheaper alternative in low-income countries.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Hardware Removal in Craniomaxillofacial Trauma: A Systematic Review of the Literature and Management Algorithm

Background

Craniomaxillofacial (CMF) fractures are typically treated with open reduction and internal fixation. Open reduction and internal fixation can be complicated by hardware exposure or infection. The literature often does not differentiate between these 2 entities; so for this study, we have considered all hardware exposures as hardware infections. Approximately 5% of adults with CMF trauma are thought to develop hardware infections. Management consists of either removing the hardware versus leaving it in situ. The optimal approach has not been investigated. Thus, a systematic review of the literature was undertaken and a resultant evidence-based approach to the treatment and management of CMF hardware infections was devised.

Materials and Methods

A comprehensive search of journal articles was performed in parallel using MEDLINE, Web of Science, and ScienceDirect electronic databases. Keywords and phrases used were maxillofacial injuries; facial bones; wounds and injuries; fracture fixation, internal; wound infection; and infection. Our search yielded 529 articles. To focus on CMF fractures with hardware infections, the full text of English-language articles was reviewed to identify articles focusing on the evaluation and management of infected hardware in CMF trauma. Each article’s reference list was manually reviewed and citation analysis performed to identify articles missed by the search strategy. There were 259 articles that met the full inclusion criteria and form the basis of this systematic review. The articles were rated based on the level of evidence. There were 81 grade II articles included in the meta-analysis.

Result

Our meta-analysis revealed that 7503 patients were treated with hardware for CMF fractures in the 81 grade II articles. Hardware infection occurred in 510 (6.8%) of these patients. Of those infections, hardware removal occurred in 264 (51.8%) patients; hardware was left in place in 166 (32.6%) patients; and in 80 (15.6%) cases, there was no report as to hardware management. Finally, our review revealed that there were no reported differences in outcomes between groups.

Conclusions

Management of CMF hardware infections should be performed in a sequential and consistent manner to optimize outcome. An evidence-based algorithm for management of CMF hardware infections based on this critical review of the literature is presented and discussed.

Complications of mandibular fracture: study of the treatment methods in calabar, Nigeria

OBJECTIVE

The plethora of techniques available for the treatment of mandibular fractures suggests that there is controversy regarding their definitive outcome. The purpose of this study was to clinically study the complications associated with the different treatment methods of mandibular fractures at the University of Calabar Teaching Hospital (UCTH), Nigeria.

METHODS

This was a three-year prospective study carried out at the Dental and Maxillofacial Clinic of the hospital. Patients who met the inclusion criteria had their data recorded in a proforma questionnaire.

RESULTS

Out of the 256 patients studied, 17.2% developed complications. Complications were commoner (70.5%) between ages 21 and 50 years. Thirty-five (79.5%) were males while nine (20.5%) were females with a male:female ratio of 4.9:1. Following treatment by closed reduction, conservative and open reduction, 16.6%, 17.2% and 20.7% had complications, respectively. Whereas occlusal derangement was the most common complication, numbness of the cheek and lower lip was recorded following all treatment methods.

CONCLUSION

Although the complications recorded in this patient population were managed during postoperative follow-up period, the methods of treatment available give good results, are cost-effective and patient compliance is good. This suggests that the older methods of treatment of mandibular fractures can still be used with reliability in contemporary dental practice.

Avoiding occlusal derangement in facial fractures: An evidence based approach

Facial fractures with occlusal derangement describe any fracture which directly or indirectly affects the occlusal relationship. Such fractures include dento-alveolar fractures in the maxilla and mandible, midface fractures - Le fort I, II, III and mandible fractures of the symphysis, parasymphysis, body, angle, and condyle. In some of these fractures, the fracture line runs through the dento-alveolar component whereas in others the fracture line is remote from the occlusal plane nevertheless altering the occlusion. The complications that could ensue from the management of maxillofacial fractures are predominantly iatrogenic, and therefore can be avoided if adequate care is exercised by the operating surgeon. This paper does not emphasize on complications arising from any particular technique in the management of maxillofacial fractures but rather discusses complications in general, irrespective of the technique used.

A Prospective Randomized Clinical Trial Comparing 3D and Standard Miniplates in Treatment of Mandibular Symphysis and Parasymphysis Fractures

PURPOSE

To compare the efficacy of the 3D miniplates to standard miniplates in the osteosynthesis of mandibular symphysis and parasymphysis fractures on the basis of clinical parameters and radiographic evaluation.

PATIENTS AND METHODS

A prospective randomized clinical trial was conducted to treat consecutive mandibular symphysis and parasymphysis fractures. The patients were randomly divided into 2 groups. The patients underwent osteosynthesis in group A with 3D titanium miniplates and in group B with conventional titanium miniplates. The cause of trauma, the number of days from injury to surgery, average age and gender were all reviewed. The assessment of the patients was done at 1, 3, and 6 weeks and 3 months using the clinical parameters and radiographic evaluation.

RESULTS

Eighty patients with isolated symphysis or parasymphysis fracture met the inclusion criteria. In our study, a statistically significant difference was not found in the clinical parameters such as pain, swelling, infection, paresthesia, hardware failure, and mobility between the fracture segments. Similarly Radiological evaluation did not show any statistically significant difference in reduction between the 2 groups. 3D plates are difficult to adapt and use sometimes, but operative time is less with them in treatment of symphysis and parasymphysis fractures.

CONCLUSION

The use of 3D miniplates for symphysis and parasymphysis fracture fixation was efficacious enough to bear the masticatory load during osteosynthesis of the fracture. Although 3D miniplate system is difficult to adapt and difficult to use in cases of fractures involving the mental nerve, they provide the advantage of less operative time and less implant material in treatment of symphysis and parasymphysis fracture, with clinical results almost similar to those seen with conventional miniplate osteosynthesis.

Effectiveness of 2.0 mm Standard and 2.0 mm Locking Miniplates in Management of Mandibular Fractures: A Clinical Comparative Study

To compare and evaluate the effectiveness of 2.0 mm locking miniplates versus 2.0 mm standard miniplates in treatment of mandible fractures. Sixty randomly selected patients who sustained mandibular fractures were selected for this study. The fractured fragments were stabilized using 2.0 mm locking miniplates in 30 cases and in the remaining 30 cases the fractured fragments were fixed with conventional 2.0 mm miniplates. Post-operative stability was assessed with radiographs at 7th day, 1st, and 3rd months. The stability of the reduced fracture was assessed clinically and both the types of plates were assessed with an OPG or conventional radiographs. This study shows favorable results on use of locking miniplates in mandibular fractures. The results show that there were no significant differences in the post-operative complications between the conventional and the locking plate/screw mandibular systems. The locking plate/screw system was more rigid than conventional plate/screw system, thereby reducing the need and duration of intermaxillary fixation (IMF).

Mandibular fracture scoring system: for prediction of complications

INTRODUCTION

Mandibular fractures are one of the most commonly encountered injuries in trauma clinics. Although several widely accepted classification systems exist, these are mostly region specific, differ in the classification criteria used, and are sometimes only correlated with specific treatment modalities, thereby making it impossible to uniformly and comprehensively document facial fracture patterns. In this study, we developed a modified scoring system for mandibular fractures and analyzed the relationship between scoring of fractures that were treated and the incidence of complications after surgical treatment.

MATERIALS AND METHODS

To evaluate the suitability of the proposed scoring system, a prospective study on a series of 116 patients was performed. All the fractures were classified using the proposed scoring system. The scoring was based on clinical and radiological evaluation of each fracture. Patients were followed up postoperatively for presence of complications.

RESULTS

A good correlation between the proposed scoring system and the incidence of complications was detected.

DISCUSSION

This scoring system for mandibular fractures facilitates an objective and standardized assessment of the degree of severity of a fracture, thereby allowing for systematic evaluation of facial fracture outcomes, including assessment of complications. However, it is our understanding that a multicenter study should be performed before the effectiveness of the proposed classification can be clearly stated.

Bite force evaluation of mandibular fractures treated with microplates and miniplates

PURPOSE

The purpose of this study was to determine the clinical stability and efficacy of 1 microplate combined with 1 miniplate in the management of mandibular fractures of the interforaminal region compared with the standard 2-miniplate treatment using bite force measurements.

MATERIALS AND METHODS

Twenty patients were treated for isolated mandibular fractures of the interforaminal region. They were randomly divided into group A (test group) and group B (control group), with 10 patients per group. Group A underwent osteosynthesis using the combination of 1 microplate (subapical) and 1 miniplate (at the lower border). Group B underwent osteosynthesis using the standard 2-miniplate protocol. The bite force measurements were performed preoperatively and postoperatively at each follow-up using a bite force recorder. As a secondary outcome, the patients also were assessed for complications, such as infection, that might interfere with successful osteosynthesis at the fracture site.

RESULTS

A statistically significant increase in incisor bite force was found in the 2 groups compared with the preoperative bite force measurements. No statistically significant difference was seen in the incisor bite force of either group at the different follow-up visits. No statistically significant difference was seen in the molar bite force (right vs left) of the test and control groups during follow-up. Molar bite force on the nonfractured side was greater than on the fractured side in the 2 groups. Infection was seen in 1 patient (ie, 10%) in each group. On surgical exploration, the fracture had united and the infection was resolved in the 2 patients, with no further complications.

CONCLUSIONS

The replacement of an upper miniplate by a microplate in the management of mandibular fractures is stable and adequately efficacious to withstand the masticatory loads and torsional forces acting in the anterior region of the mandible.

Versatility of a single upper border miniplate to treat mandibular angle fractures: A clinical study

CONTEXT

Mandibular fractures are among the most common of facial fractures. Fractures of the mandibular angle are associated with the highest incidence of postsurgical infection of all mandibular fractures. The treatment of facial fractures has traditionally involved reestablishment of a functional dental occlusion with various types of intermaxillary fixation. Treatment modalities range from simple maxillo-mandibular fixation to rigid internal fixation of the bone fragments.

AIMS

The aim of this study was to determine the versatility of the single noncompression miniplate to treat the fractures of the mandibular angle with access via an intraoral route.

MATERIALS AND METHODS

Cases of unfavorable fractures of the mandibular angle were selected for the study of intraoral surgical management of mandibular angle fractures using a single 2.0-mm noncompression miniplate.

STATISTICAL ANALYSIS AND RESULTS

An observational study was carried out on treatment of fractures of the angle of the mandible, and the findings were recorded and presented.

CONCLUSIONS

We studied the versatility of the single noncompression miniplate to treat the fractures of the mandibular angle and found no complications associated with superior border miniplate fixation of mandibular angle fractures.

Miniplate osteosynthesis with four different systems in sheep

The aim of this study was to compare a combination of a locking system with self-tapping (ST-L) or self-drilling-tapping (SDT-L) screws with a combination of conventional miniplates with self-tapping (ST) and self-forming (SF) screws. A standardized osteotomy and osteosynthesis with one of the above mentioned systems was performed in 24 sheep. Callus formation was measured with the help of CT scans assisted by a navigation system. Specimens of each osteotomy gap were taken and examined histologically. The best results were observed when self-tapping screws and the Mini-Locking-System (ST-L) were applied. The slowest healing was seen in animals treated with miniplates and SF screws. After 8 weeks an increase in bone formation could be observed in the ST, SF, SDT-L systems. The results after 8 weeks were comparable with those achieved by the ST-L system after 4 weeks. The improved stability of the osteosynthesis with the ST-L system resulted in early ossification of the osteotomy gap and the smallest amount of callus formation.

Evaluation of metal release and local tissue response to indigenous stainless steel miniplates used in facial fractures

The issue of metal release from stainless steel bone plates has gained considerable momentum advocating the removal of stainless steel miniplates after healing of fracture. So far no study has been published in the literature regarding metal release with the indigenously manufactured stainless steel miniplates.Objective Aim of the study was to find any pathological changes at cellular and ultracellular levels and metal particles in the soft tissue surrounding the stainless steel miniplates.Method Retrieval of indigenous stainless steel implants, used in treatment of jaw fractures, samples of surrounding soft tissue were histopathologically assessed for tissue response as well as metal release, using light microscope and Transmitted Electron Microscope (TEM).Result Light microscopic examination revealed chronic inflammation in symptomatic cases, but TEM did not show any significant pathological alteration and metal deposits even in cases with clinically observed pigmentation. Short-term (upto 1 year) retention of stainless steel mini plates will not cause any significant local complications.

Comparison of 3-dimensional and standard miniplate fixation in the management of mandibular fractures

PURPOSE

The aim of this follow-up study was to compare 3-dimensional (3D) and standard (Champy's) miniplate fixation in the management of mandibular fractures, and to analyze advantages and disadvantages of one over the other.

PATIENTS AND METHODS

A prospective randomized clinical trial was carried out in patients with well-defined inclusion and exclusion criteria. Patients were followed for 2 months for wound dehiscence, infection, segmental mobility, postoperative occlusion, significant period of postoperative complications, and radiological evaluation of reduction and fixation.

RESULTS

Twenty patients were enrolled in both the groups with no case of wound dehiscence. In group 1, 2 patients had mild segmental mobility (P = .07), 2 patients had surgical site infection (P = .07), and 2 patients involving mental nerve had involved roots of teeth (P = .07). Radiological evaluation did not show any statistically significant difference in reduction (P = 1.4), but showed a significant difference (P = .03) in fixation between the 2 groups, especially in cases involving the mental nerve (ie, fracture near or involving the mental foramen) and oblique fractures.

CONCLUSION

Champy's miniplate system is a better and easier method than the 3D miniplate system for fixation of mandibular fractures. In comparison, the 3D miniplate system is unfavorable for use in cases of oblique fractures and those involving the mental nerve, and is also difficult to adapt. In most cases, it provides good stability but with excessive implant material because of extra vertical bars incorporated for countering the torque forces. However, operative time is less because of simultaneous stabilization at both superior and inferior borders.

Reasons for miniplate removal following maxillofacial trauma: a 4-year study

INTRODUCTION

There is still no consensus on the need for routine removal of titanium miniplates in the maxillofacial skeleton. The purpose of this 4-year prospective study was to evaluate the reasons for removal of titanium miniplates ("2.0mm") following maxillofacial trauma.

MATERIAL AND METHODS

Records of 280 patients were evaluated concerning the number of plates inserted, the site of plating, the number of patients in whom plates were removed, the site of removal and the reasons for which removal of plates was indicated.

RESULTS

In the 280 patients with facial trauma, 599 miniplates were used during this period. Thirty-seven miniplates were removed from 27 of these patients. The main causes for removal were infection and exposure of the plate in the oral cavity, patients' request and/or the plates being palpable. The nasofrontal region, the area around the anterior wall of the antrum and the body of the mandible proved to be the commonest regions where plate removal was required.

CONCLUSION

The number of miniplates removed was small but not insignificant. There is no evidence from this study to support advice for the routine removal of titanium miniplates from the maxillofacial skeleton.

Treatment of mandibular angle fractures with a matrix miniplate: a preliminary report

Mandibular angle fractures are technically challenging, and a spectrum of techniques for treatment of these fractures has been proposed in the literature. Currently, fixation with one or two miniplates has become a widely accepted method of providing internal fixation and eliminating the need for postoperative maxillomandibular fixation. In this study, the utility of a single 2.0-mm matrix miniplate for mandibular angle fracture management was examined. In a laboratory biomechanical analysis, the overall stability of the single 2.0-mm matrix miniplate compared favorably with two 2.0-mm miniplates in a simulated fracture setting. The matrix miniplate demonstrated an overall better intrinsic stability, more resistance to out-of-plane fracture movement, and a higher load tolerance when motion out-of-plane was challenged. Clinically, the matrix miniplate performed well. In a series of 22 consecutive patients, there were no cases of nonunion, malunion, or plate failure. Two patients developed infection that was managed in both cases by drainage with maintenance of the miniplate. Both went on to full union. These results compare very favorably to previously published series using one or two miniplates.

Removal of miniplates in maxillofacial surgery: a follow-up study

PURPOSE

We sought to follow-up a cohort of patients who had miniplates (plates) inserted in the oral and maxillofacial region during a 13-month period over 4 years to study the incidence and factors associated with plate removal.

PATIENTS AND METHODS

One hundred fifty-three patients had plates inserted in the oral and maxillofacial region in the Department of Oral & Maxillofacial Surgery, University Hospital Birmingham, UK, between November 1, 1998, and November 30, 1999. All 153 patients' records were revisited on or after October 31, 2002, giving a minimum follow-up of 3 years and a maximum of 4 years.

RESULTS

During a period of 13 months (November 1, 1998 through November 30, 1999), 308 plates were inserted into 153 patients. A total of 32 plates were removed from 21 patients by October 31, 2002, (10.4%) over 4 years; 27 plates were removed from 16 patients for purely plate-related symptoms, with infection being the most common cause accounting for 16 plates (50%) in 9 patients. Symptoms necessitating plate removal occurred within 52 weeks after insertion in 16 patients, accounting for 23 of the plates removed (72%). The age of the patient at plate insertion may have some influence on plate removal but this was not significant. Seniority of the operator did not affect plate removal.

CONCLUSION

Our experience with the removal of miniplates compares with previously published reports. Longitudinal follow-up at 4 years indicates that plate-related problems leading to removal are likely to occur in the first year after insertion.

Complications and the Time to Repair of Mandible Fractures

OBJECTIVE

Treatment delays in the operative management of mandible fractures are often unavoidable. We were interested in determining whether delays increased the incidence of complications in these patients.

STUDY DESIGN AND SETTING

A retrospective chart review was performed on all patients who presented to the San Francisco General Hospital with an operative mandible fracture in 2002. On the basis of the number of days from initial injury to surgery, the patients were divided into two groups: those repaired in 3 days or less and those repaired after 3 days. The incidence of infectious and technical complications was then compared between these groups. Substance abuse was also evaluated for its role in complication risk.

RESULTS

Of the 84 patients in the study, 11 had infectious complications, and 10 had technical complications. Although treatment delay did not increase the risk of developing an infectious complication, substance abuse considerably increased this risk. The incidence of technical complications was remarkably higher in patients repaired after 3 days.

CONCLUSION

Although patients with mandible fractures treated after 3 days do not have a higher risk of developing an infectious complication, this risk is elevated in patients who abuse substances regularly. The risk of technical complications increases with treatment delay, and therefore the surgical team must be even more vigilant when reducing these fractures.

Can monocortical miniplates provide bony compression? An experimental model

Some maxillofacial surgeons advocate that screws in monocortical plate systems be placed eccentrically in an attempt to provide compression between bony ends. We sought to quantify the degree of displacement and compressive forces made possible by such eccentric placement in an experimental model using five miniplates and Perspex blocks to simulate mandibular fractures. The maximum displacement obtained was 0.67 mm and the maximal compressive force 5.2N (SEM=0.9, range=2.7-7.1). This demonstrates that eccentric placement of screws can achieve some compression and displacement at the fracture interface and that the forces obtained are close to those predictable from the dimensions of the burr, screw, and miniplate.

Complications of mandibular fractures in an urban teaching center

PURPOSE

In this study, we compared the complications associated with open and closed treatment of mandibular fractures in an urban teaching center over a 4-year period.

PATIENTS AND METHODS

We conducted a retrospective review of mandibular fracture morbidity associated with treatment by the oral and maxillofacial surgery service between 1996 and 2000. A total of 721 fractures were recorded, with 594 fractures available for review. Perioperative and postoperative complications were assessed by reviewing patient charts, operative reports, and radiographs. Complications were classified by location, type of complication, and treatment modality. Standard statistical tests were used to assess differences between the groups.

RESULTS

Of the 594 fractures available for review, a total of 79 fractures were noted to have had a complication (13.3%). One hundred five complications were observed in the group of 79 fractures due to more than one complication being associated with a specific fracture (15.8%). Closed reductions accounted for the largest treatment group, representing 341 fractures with 26 complications (7.6%). Miniplate fixation was used in 97 cases, with 23 complications (23.7%). Mandibular plates with or without a superior border miniplate were used in 140 fractures, with 28 complications (20%). The most common complication was wound infection, which occurred in 35 fracture sites, followed by nonunion, which occurred at 30 sites.

CONCLUSION

In an urban area with a high prevalence of poor living conditions, substance abuse, and poor patient compliance, the treatment of mandibular fractures by closed reduction resulted in the least number of postoperative complications in all anatomic regions of the mandible. The mandibular angle fracture had the highest overall morbidity rate.

Fixation of mandibular fractures with 2.0-mm miniplates: review of 191 cases

PURPOSE

Our goal was to study the use of 2.0-mm miniplates for the fixation of mandibular fractures.

PATIENTS AND METHODS

Records of 191 patients who experienced a total of 280 mandibular fractures that were treated with 2.0-mm miniplates were reviewed. One hundred twelve of those patients, presenting 160 fractures, who attended a late follow-up were also clinically evaluated. Miniplates were used in the same positions described by AO/ASIF. No intermaxillary fixation was used. All patients included had a minimum follow-up of 6 months. Demographic data, procedures, postoperative results, and complications were analyzed.

RESULTS

Mandibular fractures occurred mainly in males (mean age, 30.3 years). Mean follow-up was 21.92 months. The main etiology was motor vehicle accident. The most common fracture was the angle fracture (28.21%). Twenty-two fractures developed infection, for an overall incidence of 7.85%. When only angle fractures are considered, that incidence is increased to 18.98%. Although only 1 patient (0.89%) described inferior alveolar nerve paresthesia, objective testing revealed sensitivity alterations in 31.52% of the patients who had fractures in regions related to the inferior alveolar nerve. Temporary mild deficit of the marginal mandibular branch was observed in 2.56% of the extraoral approaches performed and 2.48% presented with hypertrophic scars. Incidence of occlusal alterations was 4.0%. Facial asymmetry was observed in 2.67% of the patients, whereas malunion incidence was 1.78%. Fibrous union, mostly partial, occurred in 2.38% of the fractures, but only 1 of those presented with mobility (0.59%). Condylar resorption developed in 6.25% of the fixated condylar fractures. Mean mouth opening was 42.08 mm.

CONCLUSION

The overall incidence of complications, including infections, was similar to those described for more rigid methods of fixation.

Miniplate removal in trauma and orthognathic surgery--a retrospective study

Records of patients undergoing the surgical removal of miniplates placed during the management of maxillofacial trauma (n=49) and orthognathic surgery (n=16) in a single unit, over a 2-year period have been analysed. Data concerning indications for plating, age and sex distribution, site of plating, time between insertion and removal, antibiotic prophylaxis, general medical factors and clinical indications for plate removal were evaluated for all patients. In addition, data for trauma patients included the site of fracture, and time delay between injury and plate insertion. Infection and/or wound dehiscence were the predominant causes for plate removal in both groups, in spite of the routine use of prophylactic antibiotics in a predominantly young, healthy cohort of patients.A removal rate of approximately 10% was found in the two groups of patients. This low rate would seem to imply that the routine removal of miniplates is not clinically indicated.

Complications and removal rates of miniplates and screws used for maxillofacial fractures

Complications of miniplates and screws used for maxillofacial fractures were analyzed, and complications were evaluated in relation to fracture site. Motor vehicle accidents were the cause of all fractures in this study. During the last 7 years (1994-2001), noncompressive titanium miniplates and screws were used for stabilization of maxillofacial fractures. In 66 patients, 87 fracture sites were stabilized using 296 miniplates and 1,184 screws. The mean age of the patients was 31 years (age range, 6-64 years). The percentage of male patients was 77% and the percentage of female patients was 23%. Miniplates and screws were used in 6 patients (10%) who were younger than 15 years of age at the time of the surgery. The follow-up period ranged between 3 months and 7 years. The overall miniplate and screw removal rate was 7%. The rates of removal according to the fracture site are as follows: mandible, 4.4%; zygomaticofrontal junction, 1.4%; inferior orbital rim, 0.7%; maxilla, 0.3%; and frontal sinus wall, 0.3%. Removal causes were infection, 2%; extrusion, 1.7%; visibility, 1.4%; pain, 1%; malunion, 0.7%; and miniplate fracture, 0.3%. The minimum time period between insertion and removal was 3 months and the maximum period was 14 months. Infection and extrusion were the main complications for removal of miniplates and screws from the mandible, whereas miniplates and screws were removed from the zygoma because of visibility (zygomaticofrontal region) under the skin in the vast majority of the patients. The maxilla was the least operated region for miniplate and screw removal. In all patients in this study, the preoperative physical symptoms were relieved after miniplate and screw removal. Miniplates and screws are very useful tools in maxillofacial fracture management, but sometimes they have to be removed. In the authors' series, the removal rate was 7%, and this rate can vary with the severity of the trauma and location of the fracture.

Transoral 2.0-mm miniplate fixation of mandibular fractures plus 2 weeks' maxillomandibular fixation: a prospective study

PURPOSE

We conducted a study to assess the efficacy of intraoral treatment of mandibular fractures using a 2.0-mm miniplate and 2 weeks of maxillomandibular fixation (MMF).

PATIENTS AND METHODS

Forty-four mandible fractures in 31 patients with a mean of 15 days of MMF were included in this study. A 2.0-mm miniplate was adapted along Champy's lines of ideal osteosynthesis and secured with four 8.0-mm monocortical screws. All patients were followed for at least 8 weeks after surgery. The incidences of bone or soft tissue infections, wound dehiscence, nonunion, malunion, malocclusion, plate fractures, and iatrogenic neurosensory deficits were prospectively evaluated.

RESULTS

Primary bone healing was achieved in 100% of cases. No soft or hard tissue infection, malocclusion, malunion, nonunion, dental injuries, plate fracture, or iatrogenic nerve injuries were observed. Two (4.52%) minor complications-intraoral wound dehiscences-were noted.

CONCLUSIONS

The use of a single 2.0-mm miniplate adapted along Champy's line of ideal osteosynthesis and stabilized with 4 monocortical screws plus 2 weeks of MMF was a viable treatment modality for mandibular fractures.

Treatment of mandible fractures using low-profile titanium miniplates: preliminary study

This study evaluated the short-term results of patients treated with low-profile titanium miniplates for fractures of the mandible. Thirty-one fractures of the mandible in 23 patients were treated by open reduction and internal fixation using thin, low-profile miniplates and 1.3-mm self-threading screws. Duration of intermaxillary fixation ranged from 0 to 25 days. Patients were evaluated for complications during a follow-up period ranging from 6 to 24 months. Seven patients (30.4 percent) experienced complications. These included infection (n = 1), premature occlusal contact (n = 1), wound dehiscence (n = 1), temporomandibular joint disorder (n = 1), and paresthesia (n = 3). All complications were minor and adequately managed with incision and drainage, medication, and elastic traction. Low-profile titanium miniplates can be adequately used for internal fixation in selective mandibular fractures. Advantages of these types of plates include comfort due to the thinness of miniplates and ease of application.

Maxillofacial fractures in a semi-urban Nigerian teaching hospital. A review of 442 cases

A retrospective review of 442 patients, seen by one maxillofacial unit over a twelve-year period, is presented. Data concerning the patients' demographics and the aetiology, pattern, treatment and complications of the fractures were obtained and evaluated. Approximately 72% of the patients sustained fractures from road traffic accidents and 39% of the fractures occurred in the 21-30-year range. There was a male preponderence and 8% of all cases had postoperative infections. Over 20% of the patients sustained associated body injuries and only one-third reported for treatment within 24 hours of injury. Road traffic accidents continue to be the leading cause of maxillofacial fractures. The late presentation for treatment appears to be related to the rural and semi-urban dwelling of the patients and the attendant transportation and economic difficulties.

An immunocytochemical study for lysosomal cathepsins B and D related to the intracellular degradation of titanium at the bone-titanium interface

The morphological relationship between titanium and lysosomal proteinases, cathepsins B and D, at the bone-titanium interface using titanium-coated plastic implants placed for 28 days in the tibiae of 6-week-old rats was immunocytochemically investigated by the colloidal immunogold-silver method. Under light microscopy the titanium layer appeared to make direct contact with the bone and one or a few layers of slender cells were interposed between the bone and titanium. Ultrastructurally, the titanium came in contact with the bone or the slender cell layer through a 20 to 40 nm thin amorphous zone. The slender cells at the bone-titanium interface consisted of two types; one was an osteoblast type with glycogen granules which was found along the newly-formed bone facing titanium layer. The other was a fibroblast type which came in contact with the titanium layer and occasionally endocytosed the detached titanium fragments. In addition, some of the slender cells also showed degenerative changes. Immunocytochemically, cathepsins B and/or D were sometimes colocalized in some phagolysosomes with titanium fragments. These findings suggested that the fibroblast types at the bone-titanium interface may act as scavengers to remove both cell debris and titanium by means of some endocytotic ability, and lysosomal cathepsins also developed in response to the endocytosed titanium. The osteoblast type also appears to show a high degree of osteogenic activity around the titanium-coated plastic implants.