Treatment of mandibular angle fractures: transoral internal wire fixation

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.

Transoral versus extraoral approach for mandibular angle fractures: A comparative study

INTRODUCTION

Mandibular fractures represent approximately two-thirds of all the maxillofacial fractures (nearly 70%) out of which fractures of mandibular angle represent for 26-35%.

AIM OF THE STUDY

The aim of this study is to compare the transoral and extraoral (submandibular) approaches for fixation of mandibular angle fractures.

OBJECTIVES OF STUDY

The objectives of the following study are to evaluate ease of accessibility, time taken for the procedure, ease of anatomic reduction and complications.

MATERIALS AND METHODS

A prospective study was carried out in 30 patients reporting to the Department of Oral and Maxillofacial surgery, Narayana Dental College and Hospital, Nellore, Andhra Pradesh during the period of months from November 2011 to August 2013 who were randomly divided in two groups based on computer generated simple randomization chart. Group I patients underwent transoral reduction and fixation and Group II patients underwent extraoral reduction and fixation. The ease of accessibility was analysed by visual analogue scale by the operating surgeon, time taken from incision to closure with digital clock, difficulty level index of surgeon based on the time taken for the procedure and approach related complications.

RESULTS

The ease of accessibility in Group I was good in 53.3% while in Group II patients approached extraorally it was good in 86.7%. Group I patients approached transorally showed a mean of 49.7 min while that of Group II patients approached extraorally showed a mean of 73.4 min. Group I had a minimum difficulty level index in 60%, moderate difficulty level in 33.3% and severe difficulty level in 6.7% while Group II had a minimum and moderate difficulty level in 46.7% and severe difficulty level in 6.7%. There was 1 (6.7%) complication reported in each group.

CONCLUSION

The statistical analysis of this study concludes that fracture line starting anterior to mandibular third molar and ending at anteroinferior border of the insertion of the masseter muscle or posterior body of mandible can be approached transorally. Fracture line starting posterior or distal to the third molar or posterior to the insertion of the masseter muscle to the angle of the mandible or fracture line extending high in the ramus, extraoral approach provides a better choice for reduction and fixation of the fractured segments with restoration of anatomical and functional occlusion.

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.

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.

Superior Border Plating Technique in the Management of Isolated Mandibular Angle Fractures: A Retrospective Study of 50 Consecutive Patients

PURPOSE

To determine the complication rate for patients presenting with isolated mandibular angle fractures treated by open reduction and internal fixation using a single superior border miniplate technique.

PATIENTS AND METHODS

This is a retrospective study of consecutive patients with isolated mandibular angle fractures treated using a specific protocol at a Regional Oral and Maxillofacial Department between January 1998 and December 2004. Patient demographics, fracture etiology, length of hospital stay, removal of third molar, and postoperative complications were recorded. Preoperative and postoperative inferior alveolar nerve function was recorded. Objective sensory testing and patient interviews were conducted to determine the incidence of postoperative sensory deficit.

RESULTS

The study population included 50 patients presenting with isolated mandibular angle fractures, 6 patients (12%) experienced complications requiring bone plate removal. These complications were minor and occurred after fracture healing as follows: 4 patients (8%) experienced superficial soft tissue infection associated with the bone plate, treated with oral antibiotics, 1 patient (2%) experienced bone plate exposure, and a further patient (2%) presented with a fractured bone plate. All 6 patients (12%) were treated by bone plate removal under general anesthesia as elective day case surgery. Thirty-nine (78%) patients had long-term sensory follow-up, mean 37 months (2 to 84 months). Permanent inferior alveolar sensory deficit (>12 months) was present in 4 (8%). Five of 26 (19%) patients with normal postinjury/preoperative sensory function had a postoperative sensory deficit. All patients in this group reported recovery of normal sensation within 6 months.

CONCLUSIONS

The results of this study suggest that the complication rates associated with the treatment of isolated mandibular angle fractures using a superior border plating technique, in this patient population, is relatively low (12%). The complications were all minor in nature. There was a permanent (>12 months) inferior alveolar sensory deficit in 4 (8%) patients.

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.

Treatment of mandibular fractures with rigid osteosynthesis: using the AO system

PURPOSE

This study evaluated the results achieved in the surgical treatment of all mandibular fractures at two university centers using the 2.7 AO mandibular system.

PATIENTS AND METHODS

A total of 227 patients presenting with 180 single fractures and 47 with double fractures (274 osteosyntheses) were included in this prospective study.

RESULTS

During a mean follow-up of 27.5 months (minimum, 12 months), an overall complication rate of 7% was observed. No infection justified early removal of the osteosynthesis material.

CONCLUSIONS

The systematic use of the technique recommended by AO for treating mandibular fractures, performed by thoroughly experienced operators on a compliant population, results in a low rate of complications and an early return to normal function.

A three-dimensional study of loads across the fracture for different fracture sites of the mandible

The loads across the fracture depend on variables such as position of the fracture and the bite point. Up to now, no study has described systematically the influence of these two variables on these loads. The aim of this study was to describe and compare value and direction of the loads across the fracture for different positions of fractures in the mandible. In a three-dimensional model, bending and torsion moments and shear forces were compared for five mandibular fractures. The fractures were located in, respectively, the angle, posterior body, anterior body, canine and symphysis region. Positive bending moments were defined to give compression at the border, negative bending moments to give compression at the alveolar side of the mandible. The angle and posterior body fracture have high positive bending moments, small torsion moments and high shear forces. The anterior body, canine and symphysis fracture have high negative bending moments and high torsion moments with similar maximum values. The number of bite points with negative bending moments were different for all fractures. These bite points were always located on the fractured side. It is concluded that mandibular fractures can be divided roughly into two groups with similar load patterns across the fracture. One group consists of angle and posterior body fractures, the other group consists of anterior body, canine and symphysis fractures.

Cost-effectiveness analysis of open reduction/nonrigid fixation and open reduction/rigid fixation to treat mandibular fractures

OBJECTIVES

When open reduction and internal fixation is indicated for the management of mandibular fractures, it is generally agreed that nonrigid fixation and rigid fixation represent acceptable treatment alternative. Opinions vary, however, regarding the cost-effectiveness of the two alternative. The purpose of this study was to compare the costs of these treatments of mandibular fractures that required open reduction and internal fixation.

STUDY DESIGN

Cost-effectiveness analysis was used to determine the most efficient resource used to treat mandibular fractures requiring open reduction and internal fixation. Cost-effectiveness was defined as the treatment charges per successfully treated patient. Data were collected retrospectively from patients with mandibular fractures treated between 1991 and 1994. The patient's medical record and hospital billing record were used as data sources. To estimate treatment charges, the sample was divided into three groups: (1) group 1, patients treated with nonrigid fixation without postoperative complications, (2) group 2, patients treated with rigid fixation without postoperative complications, and (3) group 3, patients treated with either procedure who had postoperative complications. The study variables were grouped into two categories: clinical information and charges. Treatment charges for both treatments were estimated and compared.

RESULTS

Data were collected for 12 patients in group 1 and 11 patients in group 2. Costs for rigid fixation averaged $1,468 more per patient than for nonrigid fixation in uncomplicated cases. There were 11 patients in group 3. The average cost to treat a postoperative complication was $11,637. Given the institution-specific treatment cost and the probability of complications, rigid fixation was a more cost-effective treatment than nonrigid fixation.

CONCLUSION

Cost estimates for treating mandibular fractures may vary widely depending on practice patterns and complication rates. Despite these cost variations, one may determine the most cost-effective treatment alternative by estimating treatment costs of both uncomplicated and complicated cases and the postoperative complication rate.