Rigid internal fixation for the treatment of infected mandibular fractures

Surgical treatment of clinically infected mandibular fractures

PURPOSE

To clarify reasons for infections, surgical techniques, and occurrence of postoperative surgical site complications in infected mandibular fractures.

METHODS

Patients with clinically infected mandibular fracture of the dentate part without preceding surgery were studied retrospectively. Clinical infection was defined to occur if pus, abscess, or a fistula in the fracture area was present. Patient-, fracture-, and surgery-related variables were evaluated, and predictors for postoperative complications were analysed.

RESULTS

Of 908 patients with surgically treated fracture in the dentate part of the mandible, 41 had infected fracture at the time of surgery (4.5%). Of these patients, 46.3% were alcohol or drug abusers. Median delay from injury to surgery was 9 days. Patient-related factors were the most common cause for delayed surgery (n = 30, 73.2%), followed by missed diagnosis by a health care professional (n = 8, 19.5%). Twenty-two fractures were treated via extraoral approach (53.7%) and the remaining 19 intraorally (46.3%). Postoperative surgical site complications were found in 13 patients (31.7%), with recurrent surgical site infections predominating. Notable differences between total complication rates between intraoral and extraoral approaches were not detected. Secondary osteosynthesis for non-union was conducted for one patient treated intraorally.

CONCLUSIONS

Postoperative surgical site complications are common after treatment of infected mandibular fractures, and these occur despite the chosen surgical approach. Infected mandibular fractures heal mainly without bone grafting, and non-union is a rare complication. Due to the high complication rate, careful perioperative and postoperative care is required for these patients.

Osteosynthesis-associated infection in maxillofacial surgery by bacterial biofilms: a retrospective cohort study of 11 years

OBJECTIVES

The aim of this retrospective cohort study was to determine risk factors for osteosynthesis-associated infections (OAI) with subsequent necessity of implant removal in oral and maxillofacial surgery.

MATERIALS AND METHODS

A total of 3937 records of patients who received either orthognathic, trauma, or reconstructive jaw surgery from 2009 to 2021 were screened for osteosynthetic material removal due to infection. Treatment-intervals, volume of applied osteosynthetic material, and respective surgical procedures were also assessed. Moreover, intraoperatively harvested microbial flora was cultured and subsequently identified by MALDI TOF. Bacteria were then screened for antibiotic resistance via VITEK system or, if necessary, via agar diffusion or epsilometer test. Data was analyzed utilizing SPSS statistical software. For statistical analysis of categorical variables, chi-square tests or Fisher exact tests were used. Continuous variables were compared via non-parametric tests. The level of significance for p-values was set at < 0.05. Descriptive analysis was also performed.

RESULTS

The lower jaw was more prone to OAI than the mid face region. Larger volumes of osteosynthetic material led to significantly more OAI, resulting in reconstruction plates bearing the highest risk for OAI especially when compared to small-volume mini-plates frequently applied in trauma surgery. Among OAI associated with implant volumes smaller than 1500 mm3, the detection of Streptococcus spp., Prevotella spp., Staphylococcus spp., and Veillonella spp. was significantly elevated, whereas implant volumes larger than 1500 mm3 showed a significant increase of Enterococcus faecalis, Proteus mirabilis and Pseudomonas aeruginosa. High susceptibility rates (87.7-95.7%) were documented for 2nd- and 3rd-generation cephalosporines and piperacillin/tazobactam.

CONCLUSION

High material load and lower jaw reconstruction bear the greatest risks for OAI. When working with large volume osteosynthetic implants, gram-negative pathogens must be considered when choosing an appropriate antibiotic regime. Suitable antibiotics include, e.g., piperacillin/tazobactam and 3rd-generation cephalosporines.

CLINICAL RELEVANCE

Osteosynthetic material utilized in reconstructive procedures of the lower jaw may be colonized with drug-resistant biofilms.

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.

An algorithm for the treatment of noncondylar mandibular fractures

An algorithm for the treatment of noncondylar mandibular fractures is presented based on outcomes from studies that have been performed during the past 30 years. It is designed to assist clinicians in formulating a treatment plan that can be expected to provide the patient with a predictable outcome.

Contemporary management of infected mandibular fractures

The treatment of infected mandibular fractures has advanced rather dramatically over the past 50 years. Immobilization with maxillomandibular fixation and/or splints, removal of diseased teeth in the fracture line, external fixation, use of antibiotics, debridement, and rigid internal fixation has played a role in management. Perhaps the most important advance was the realization that infected fractures also result from moving fragments and nonvital bone, not just bacteria. Controlling movement and eliminating the dead bone allowed body defenses to also eliminate bacteria. The next logical step in the evolution of treatment was primary bone grafting of the resulting defect following application of rigid internal fixation and debridement of the dead bone. We offer our results with this treatment in 21 infected fractures, 20 of which achieved primary union.

Reconstruction of osteomyelitis defects of the craniofacial skeleton

Osteomyelitis of the craniofacial skeleton closely resembles osteomyelitis elsewhere in the body in its pathophysiology and medical management; subsequent reconstruction after debridement remains distinctly challenging. The goals of reconstruction must include the restoration of the complex and readily visible morphology of the cranium and face, as well as the adequate return of vital sensory, expressive, and digestive functions. In this article, the various reconstructive modalities will be discussed including pedicled and nonpedicled flaps with or without an osseous component, nonvascularized bone grafts, alloplastic implants, and bone regeneration using protein therapy. Although reconstruction of craniofacial defects after osteomyelitis commonly proves formidable, the satisfactory return of form and function remains a plausible reconstructive goal.

Rigid internal fixation of infected mandibular fractures

PURPOSE

To evaluate the treatment outcomes of rigid internal fixation for the management of infected mandible fractures.

PATIENTS AND METHODS

A retrospective chart review of infected mandible fractures managed by a single oral and maxillofacial surgeon at a level I trauma center during a 7-year period was accomplished by independent examiners. All patients were treated with incision and drainage, culture and sensitivity testing, extraction of nonsalvageable teeth, placement of maxillomandibular fixation when possible, fracture reduction with bone debridement and decortication, rigid internal fixation of the mandible by an extraoral approach, and antibiotic therapy. The medical and social history was contributory in most patients. The analysis was stratified by the differentiation of the fractures into 2 groups: those with soft tissue infections in the fracture region versus those with hard tissue-infected fractures (biopsy-proven osteomyelitis).

RESULTS

A total of 44 patients were included in this study, with an average follow-up of 18.2 months from the date of surgery (range 3 to 48). The treatment protocol was successful in all 18 patients (100%) with soft tissue infected mandibular fractures and 24 (92%) of 26 patients with hard tissue-infected fractures.

CONCLUSIONS

A protocol consisting of concomitant incision and drainage, mandibular debridement, fracture reduction, and stabilization with rigid internal fixation can be effectively used for single-stage management of infected mandible fractures.

Bicortical extraoral plating of mandibular fractures

The goal of bicortical fixation of mandibular fractures is to provide for undisturbed healing and immobility of fragments to facilitate primary bony union. This type of fixation should provide sufficient rigidity for fracture segments to resist any movement along the fracture line during normal function of the mandible. The decision of which technique to use for fixation of a particular mandible fracture depends on multiple factors, such as fracture location, favorability of fracture vectors, anatomic location of fractures, systemic health of the patient, timing of surgery, experience of the surgeon, age of the patient, and patient compliance. In this chapter, the authors discuss the indications and techniques of bicortical fixation of mandible fractures.

Incidence, microbiological findings, and clinical presentation of sternal wound infections after cardiac surgery with and without local gentamicin prophylaxis

Sternal wound infection (SWI) is a serious complication after cardiac surgery. In a previous randomized controlled trial, the addition of local collagen-gentamicin in the sternal wound before wound closure was found to significantly reduce the incidence of postoperative wound infections compared with the routine intravenous prophylaxis of isoxazolyl-penicillin only. The aims of the present study were to analyse the microbiological findings of the SWIs from the previous trial as well as to correlate these findings with the clinical presentation of SWI. Differences in clinical presentation of SWIs, depending on the causative agent, could be identified. Most infections had a late, insidious onset, and the majority of these were caused by staphylococci, predominantly coagulase-negative staphylococci. The clinically most fulminant infections were caused by gram-negative bacteria and presented early after surgery. Local administration of gentamicin reduced the incidence of SWIs caused by all major, clinically important bacterial species. Propionibacterium acnes was identified as a possible cause of SWI and may be linked to instability in the sternal fixation. There was no indication of an increase in the occurrence of gentamicin-resistant bacterial isolates in the treatment group. Furthermore, the addition of local collagen-gentamicin reduced the incidence of SWIs caused by methicillin-resistant coagulase-negative staphylococci. This technique warrants further evaluation as an alternative to prophylactic vancomycin in settings with a high prevalence of methicillin-resistant Staphylococcus aureus.

A review and update of new methods for immobilization of the mandible

In 1948, Dr Kurt H Thoma, a leading authority of the day, published a paper on new methods for immobilization of the mandible in the first issue of this Journal. He reviewed the state of the art for management of patients with fractures of the mandible. By reviewing the paper now we can see how difficult to treat some of the injuries he saw were. This paper assesses his patient management in light of today's knowledge and experience. It discusses changes in therapy that have occurred during this over fifty-year time span. Although many things have changed since then, what has not changed is our desire to provide the best care for our patients using currently available scientific knowledge and clinical evidence.

The Use of Immediate Bone Grafting in Reconstruction of Clinically Infected Mandibular Fractures: Bone Grafts in the Presence of Pus

PURPOSE

Current approaches to the treatment of infected mandibular fractures include antibiotics, drainage, immobilization of the segments, and debridement followed by secondary bone grafting of residual defects once the infection is resolved and the wound healed. Over the past 30 years, the time from debridement to grafting has diminished from several months to a few weeks. We present our experience with a treatment model managing clinically infected fractures of the mandible with antibiotics, debridement, rigid internal fixation, and immediate autogenous bone grafting.

MATERIALS AND METHODS

In this retrospective study, we present a series of 43 patients who demonstrated clinical/laboratory findings consistent with infection in one or more mandibular fractures (50 infected fractures). These patients underwent a combination of incision and drainage, fracture debridement, rigid internal fixation, and immediate bone grafting of the resulting defect in a single stage. Both transoral and transfacial approaches were used.

RESULTS

Of the 50 fractures, 43 showed both resolution of infection and bony union of fractures with long-term follow-up of 2 months to 4 years. Four fractures developed recurrent infection but proved to have bony union and were successfully treated by hardware removal only. Three other patients were deemed failures with persistent infection, loss of graft, nonunion, and need for retreatment. Each of these patients was afflicted with underlying immunocompromise.

CONCLUSIONS

Although careful patient selection is a must, immediate bone grafting of infected mandibular fractures, when used in conjunction with rigid internal fixation and appropriate intraoperative debridement, is an effective treatment modality which allows a single surgical procedure and dramatically shortens the course of treatment.

Infections associated with locking reconstruction plates: a retrospective review

PURPOSE

In this study, we examined the incidence of infection with the use of a locking reconstruction bone plate/system.

PATIENTS AND METHODS

All patients, treated with a locking reconstruction bone plate/screw system for mandible fractures in the Oral and Maxillofacial Surgery service over a 28-month period at a level I trauma center, were evaluated through a retrospective chart review by independent examiners. The use of a locking reconstruction plate was determined by the attending staff involved in the patient's care. Patient population included single, bilateral, and comminuted fractures. Patient characteristics were noted and include dentate versus edentulous, smoking history, and history of previous infection.

RESULTS

Fifty-six locking bone plates were placed in 42 patients. Eight (19%) of the patients were infected before treatment. A persistent infection remained in 3 of these 8 patients (37.5%). Two patients (5.8%), with 3 fracture sites (6.4%) developed postoperative infection that required further intervention. All 5 of the patients who were infected after surgery were heavy smokers. History of preoperative infection and smoking appear to be significant factors in the etiology of postoperative infection. All postoperative infections resolved successfully with local measures and with no loss of fixation.

CONCLUSION

The use of locking reconstruction plates can facilitate the management of complicated fractures; however, it does not eliminate complications. Postoperative infections are related to numerous factors, including preoperative incidence of infection, smoking, and proper use of the plates.

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.

Use of an orthopaedic fixator for external fixation of the mandible

A patient presented with a chronically infected, non-united fracture of the mandible, with considerable bone loss. He was treated with a metacarpal fixator, the miniPennig external fixator. The fixator is stable and smaller than conventional mandibular fixators. It can be applied and removed under local anaesthesia, if necessary, requires little maintenance and produces minimal scarring. The successful outcome in this patient is encouraging and we commend the use of the fixator in similar difficult cases.

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.

Type A immunoglobulin deficiency presenting as a mixed polymicrobial brain abscess: case report

OBJECTIVE AND IMPORTANCE

We present a case report of a patient with a left frontal brain abscess. Cultures obtained from the abscess at the time of surgery were identified as dental flora known to establish a synergistic relationship in polymicrobial infections. This type of synergistic relationship makes the clearance of an infection more difficult for an intact immune system. A serum immunoglobulin (Ig) Type A deficiency was identified postoperatively. This immunodeficiency may have contributed to the development of the abscess.

CLINICAL PRESENTATION

The patient presented with headaches and photophobia. Computed tomography of the head performed with intravenously administered contrast demonstrated a left frontal brain abscess.

INTERVENTION

The patient was operated on through a left frontal approach, carefully avoiding the frontal sinus. The abscess was aspirated, and the patient was treated with intravenous antibiotics for several weeks. Postoperatively, the patient did well. There were no signs of enhancement on follow-up computed tomographic scans at 7 and 12 months postoperatively.

CONCLUSION

Through a comprehensive immunological workup, an IgA deficiency was identified postoperatively. Although the deficiency of a single type of Ig may be asymptomatic, complications from recurrent or chronic bacterial infections may occur. The deficiency of IgA, combined with a synergistic polymicrobial infection, contributed to the development of an intracranial abscess. A patient presenting with a brain abscess without any predisposing medical history should be evaluated for an underlying immune deficiency.

Rigid fixation with teeth in the line of mandibular fractures

The treatment results and the incidence of complications were evaluated retrospectively in a group of 68 patients. They all had mandibular fractures with a tooth in the line of fracture and were treated using miniplates for fixation. The follow up ranged from 1 to 6 years (mean 2.6 years) and 90 fracture sites were involved. Results showed that the incidence of complications when the tooth was extracted was higher (3/12) than when it was left in place (8/78). With regard to both healing of the fracture and fate of the tooth in the line of fracture, it is recommended to retain teeth in the line of fracture, unless there is an absolute indication for extraction. It is advisable to monitor the vitality of teeth adjacent to the fracture line for at least one year.

Rigid fixation and strain patterns in the pig zygomatic arch and suture

PURPOSE

In orthognathic surgery, rigid fixation is routinely used to hold together bone fragments that may experience heavy force from attached masticatory muscles. Internal fixation plates are assumed to hold bony parts rigidly, but the mobility at such sites subjected to normal masticatory function has not been measured. The purpose of this study was to investigate in vivo the degree to which a linear plate immobilizes separated bones, specifically sutures.

MATERIALS AND METHODS

Three female miniature pigs (Sus scrofa) had 1.3-mm Synthes titanium plates placed across the suture in the zygomatic arch. Foil strain gauges were used to record load deformation in the zygomatic and squamosal (temporal) bones and across the vertical and horizontal parts of the suture. Strain was recorded in vivo during mastication and in anesthetized pigs with electrical stimulation of masticatory muscles.

RESULTS

Strain at the suture was not reduced from normal levels. The plate induced increases in strain within the bones, but the changes were slight.

CONCLUSION

The results indicate that linear "rigid fixation" does not immobilize sutures.

The effect of infection and lag screw fixation on revascularization and new bone deposition in membranous bone grafts in a rabbit model

We have suggested that rigid fixation of membranous bone grafts in the presence of infection may improve graft-recipient bone union by facilitating graft revascularzation. To test this hypothesis, we grafted autogenous membranous bone grafts to the mandibles of 94 New Zealand White rabbits. Lag screw fixation was applied in half the animals. The wounds were inoculated with a range of Staphylococcus aureus doses. Infected and noninfected rabbits were injected weekly over a 5-week course with fluorescein bone markers and with a marker of vascular endothelium (procion red) just prior to sacrifice. Revascularization and new bone deposition in the grafts were then quantified histologically for the 75 rabbits available for data collection. Infection decreased the amount of graft revascularized and the amount of new bone deposited for both rigidly fixated and nonfixated grafts. Grafts fixated with a lag screw showed a greater amount of revascularization and new bone deposition in the presence and absence of infection when compared with nonfixated grafts, supporting the hypothesis that rigid fixation of membranous bone grafts in the presence of infection may promote graft survival and union by improving revascularization and osteogenesis within the graft.

Treatment of mandibular angle fractures using one noncompression miniplate

PURPOSE

This study evaluated the results in patients treated for fractures of the mandibular angle with a single miniplate.

PATIENTS AND METHODS

Eighty-one patients with fractures of the mandibular angle were treated by open reduction and internal fixation using one noncompression miniplate with 2.0-mm self-threading screws placed through a transoral incision. No patient was placed into postsurgical maxillomandibular fixation. They were prospectively studied for complications.

RESULTS

Thirteen patients with angle fractures (16%) experienced complications requiring secondary surgical intervention. Most of the complications (n = 11), however, were minor and could be treated in the office. Most commonly, intraoral incision and drainage and later removal of the bone plate were required. All patients with minor complications had clinical union. Only two complications required hospitalization for intravenous antibiotics and further surgery. One of these patients had a fibrous union requiring a bone graft.

CONCLUSIONS

The use of a single miniplate for fractures of the angle of the mandible is a simple, reliable technique with a relatively small number of major complications.

Mandibular fracture osteosynthesis: a comparison of three techniques

The authors report on a retrospective study of 205 consecutive patients at the Maxillofacial Unit of The Royal Melbourne Hospital to assess if adherence to Champy's principles in placement of miniplates in mandibular fractures minimises morbidity. 205 well documented cases of mandibular fractures treated with internal fixation, January 1985 to April 1990 were studied. The patients were assigned into three groups according to the type of fixation; 83 patients had miniplate fixation according to Champy's principles, 40 patients had miniplate fixation ignoring Champy's principles, 82 patients had transosseous wire (TOW) fixation. Outcome was measured by preoperative variables (age, gender, mechanism of fracture, site and number of fractures, nerve function, associated injuries and treatment delay) and postoperative variables (duration of admission, duration of intermaxillary fixation (IMF), malocclusion, infection, dehiscence, union, removal of fixation and nerve function which were assessed and compared. The results show that the preoperative variables were statistically similar in all groups. The postoperative variables indicated a statistically higher complication rate for the transosseous wire group compared with the miniplate groups, and morbidity was reduced in the group following Champy's principles. The morbidity rates in this study compare favourably with other studies even though the patients in this study had a much higher incidence of multiple fractures. Titanium miniplates appear as effective as miniplates constructed of other materials used in previous studies, especially when Champy's principles are followed.

Mandible fracture repair: specific indications for newer techniques

Mandible fracture repair is commonly undertaken by otolaryngologists. Although the essential principles of reduction and immobilization are undisputed, the approach used to obtain these goals varies considerably. We performed a critical evaluation of all mandible fractures treated at the Santa Clara Valley Medical Center by the otolaryngology service between January 1988 and February 1992, with the purpose of better defining the indications for plate fixation and for the use of more traditional techniques. One hundred eighty-three fractures in 112 patients were evaluable. Thirty-six (32.1%) of these patients had at least one plate placed (group A); 39 (34.8%) underwent an open procedure, with interosseous wire fixation (group B); and 37 (33.0%) were treated with closed techniques (group C). The severity of fracture (indexed by comminution, presence of infection, teeth in the fracture line, interval to repair, and whether the fracture was open or closed) was similar in plated and nonplated mandibles. Mean (+/- standard deviation) operative times for the three groups were 3.2 +/- 1.6 hours for group A, 3.0 +/- 0.9 hours for group B, and 1.4 +/- 0.5 hours for group C. The number of follow-up visits required was not statistically different (group A, 5.6 +/- 3.8 visits; group B, 5.2 +/- 2.5 visits; and group C, 5.3 +/- 2.0 visits). The overall incidence of major complications was 14.3% (16 of 112), including 11 of 36 (30.6%) in group A, 4 of 39 (10.3%) in group B, and 1 of 37 (2.7%) in group C.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of rigid internal fixation in mandibular fractures complicated by osteomyelitis

PURPOSE

Reports on treatment of "infected" mandibular fractures with open reduction and rigid internal fixation (RIF) consist of either isolated cases or mixed series of patients with soft tissue infections or inadequately documented osteomyelitis. The definition of "infected fracture" is often vague and may include both soft tissue or bone sepsis.

MATERIALS AND METHODS

In this retrospective study, seven patients with mandibular fractures and documented osteomyelitis were treated by a protocol that included open reduction and RIF. Technetium-99m methylene diphosphonate (99mTc) and Indium 111 (111In) radionuclide scans, bone cultures, and microscopic examination were used to document the diagnosis of osteomyelitis. The infections were treated with antibiotics, incision and drainage, and surgical debridement. Reconstruction plates that were large enough to provide four holes in each bone segment were used for RIF of the fractures and simultaneous reconstruction of the osseous defects.

RESULTS

After an average follow-up of 26 months, all patients remained infection free, and the fracture sites were stable. Five of the seven patients had inferior alveolar nerve dysfunction after treatment; no other significant complications were noted.

CONCLUSION

The results of this study indicate that the protocol of simultaneous debridement, reduction, and RIF is a satisfactory method for treatment of mandibular fractures complicated by osteomyelitis. Prospective studies and longitudinal follow-up of larger numbers of patients would be desirable to confirm these findings.

Teeth in the Line of Mandibular Fractures

D Nickerson, D McPhalen. Teeth in the line of mandibular fractures. Can J Plast Surg 1994;2(3):113-116. This study considers 710 mandibular fractures occurring in 546 patients over a five-year period and notes the fate of 114 teeth involved in the line of 104 of these fractures. Analysis of retention versus removal of teeth in the fracture line and any associated infection was undertaken. Overall, 15.5% of cases that involved retained teeth became infected, as compared with 7.1% of cases in which a tooth was extracted from the fracture site. for third molars, the teeth most commonly involved in mandibular fractures, infection was associated with 20.5% of retained teeth and 10% of cases where teeth were extracted from the fracture site. These data support careful consideration of a tooth's disposition before a decision regarding retention or extraction is made. Furthermore, they suggest that even in the absence of a grossly evident risk factor for infection, such as a fractured tooth, the tooth itself may inherently predispose to infection if retained. Infection rates were higher for retained teeth regardless of whether open reduction with rigid internal fixation or closed reduction with maxillomandibular fixation was used.

Treatment of mandibular angle fractures using the AO reconstruction plate

Fifty-two patients with fracture of the mandibular angle were treated by extraoral open reduction and internal fixation using the AO reconstruction bone plate (Synthes, Paoli, PA). None were placed into postsurgical maxillomandibular fixation. Four patients developed early infections requiring incision and drainage (7.5%). One patient required removal of the hardware after the fracture had healed. The use of the AO reconstruction bone plate for fractures of the mandibular angle was found to be very predictable and was associated with a low rate of complications.