Evaluation of mandibular fracture treatment

Versatility of Titanium Mesh in Comminuted Maxillofacial Fractures. A Retrospective Study

Background

Titanium mesh provides three-dimensional stability, it is easier and quick in placement, highly malleable and adaptable hence, proved to be worth in restoring the function and form in cases of comminuted maxillofacial fractures.

Materials and Methods

A total of 12 patients were included in this retrospective study at Department of Oral and maxillofacial surgery, Sri Rajiv Gandhi College of Dental Science and Hospital, from December 2015 to June 2020. Out of 12 patients, 7 reported with frontal bone fracture and 5 reported with mandibular fracture. Patients were followed up for upto 18 months to evaluate efficacy of titanium mesh on postoperative long-term healing, aesthetic outcomes and return to normal function were evaluated.

Results

The results have shown that titanium mesh has low complication rates and the ability to maintain occlusion and chewing postoperatively. Union occurred without complication in 90% of fractures, and patients treated for frontal bone fracture had excellent cosmetic results.

Conclusion

The semi rigid nature of the titanium mesh fixation allows micro movement at the healing bone ends, reduces stress shielding effect which may improve functional bone healing. Bony continuity of the mandible can be restored providing three-dimensional morphology and stability. The versatile placement of screws is the principal advantage.

Modified high-submandibular appraoch for open reduction and internal fixation of condylar fracture: case series report

OBJECTIVES

Recently a modified high-submandibular approach (HSMA) has been introduced for treatment of condylar fracture. This approach involves an incision line close to the mandibular angle and transmasseteric transection, leading to a low incidence of facial palsy and allowing good visualization of the condyle area, especially the condylar neck and subcondyle positions. This study reports several cases managed with this modified HSMA technique for treating condylar fractures.

MATERIALS AND METHODS

Six cases of condylar fractures treated with modified HSMA technique were reviewed.

RESULTS

Three unilateral subcondylar fracture, 1 bilateral subcondylar fracture, 1 unilateral condylar neck fracture, 1 unlateral simultaneous condylar neck and subcondylar fracture cases were reviewed. All the cases were successfully treated without any major complication.

CONCLUSION

Reduction, fixation, and osteosynthesis of condylar fractures via the modified HSMA technique enabled effective and stable treatment outcomes. Therefore, the described approach can be used especially for subcondylar and condylar neck fractures with minimal complications.

Comparative Evaluation of Conventional Miniplates, Three-Dimensional Miniplates and Lag Screws for Internal Fixation of Parasymphysis Fracture of Mandible-A Double-Blind Randomized Clinical Study

Purpose

The aim of this study is to clinically and radiographically evaluate the stability of parasymphysis fracture managed with lag screws, miniplates and 3D miniplates.

Materials and Method

Ninety- eight patients diagnosed with parasymphysis fracture were treated using lag screws in group 1, two 4-hole miniplates in group 2 and 3D miniplates in group 3. Intraoperative stability and duration of fixation was assessed. Postoperative clinical evaluation was done at 1 week, 1 month, 3rd month, 6th month and 1 year for complications and oral function. Radiological evaluation was done at 3rd and 6th month. Only 92 patients were considered for statistical analysis since 6 patients were lost during follow-up.

Results

Road traffic accident (65.3%) was the primary cause of mandibular fractures. Postoperative pain score showed a statistically significant difference after 1 week and 1 month duration (P value < 0.001). ANOVA test showed VAS was significantly higher at pre-op followed by 1st day and 1 week, but no significant difference after 3 months in all groups. Radiographic analysis did not show significant difference in approximation of fracture segment among 3 groups after 6 months (P-value = 0.117). Chewing efficiency at 6 months and occlusion by surgeon evaluation at 3 months showed a significant difference (P value < 0.001).

Conclusion

Lag screw fixation was technique-sensitive, relatively inexpensive and was less time consuming method when compared to miniplates and 3D plates. Lag screws and 3D plates are superior in reducing the incidence of complications and better in oblique or sagitally displaced mandibular fractures.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12663-021-01647-5.

A comparative evaluation of retromandibular versus Modified Risdon approach in surgical treatment of condylar fracture

The purpose of this study was aimed to compare the efficiency and safety of retromandibular versus modified Risdon approach using periangular incision for open reduction and internal fixation of low subcondylar mandibular fracture. Open reduction and internal fixation with different plating systems were utilized via retromandibular approach (group I) and via modified Risdon approach with periangular incision (group II). Twenty four (n= 24) condylar fractures in 21 adult patients were divided randomly into two equal groups (12 each) according to the cutaneous incision (approach) utilized. The evaluation score for scarring in group I it was excellent in 9 patients, good in 2 patients and acceptable in only one patient (Mean 2.4 ± SD 3.38). While in group II was excellent in 10 patients and good in 2 patients (Mean 2.4 ± SD 3.87) and the p value was 0.591. Symptoms of transient facial nerve weakness were noted in only 3 patients in group I with slight to moderate dysfunction (Mean 2 ± SD 3.21), while only one patient had facial nerve weakness in group II with House - Brackman score of 2 immediate postoperatively and this got resolved in 6 weeks (Mean 2 ± SD 4.04) and the p value was 0.00022. Within the limitations of the study it seems that a modified Risdon approach using periangular incision for reduction and fixation of low subcondylar fracture should be preferred whenever possible because it yields better outcomes.

Immediate Treatment of Complex Mandible Fracture in a Pediatric Patient

The facial fractures in pediatric patients are rare, and they can need an immediate treatment to recover the function and aesthetic to the young patients. However, the open reduction internal fixation is controversial in pediatrics; it can be effectiveness to treat complex mandible fractures. Therefore, we present a case of a pediatric patient with a complex mandible fracture caused by an auto accident. The immediate treatment was successful with the use of open reduction internal fixation.

European Maxillofacial Trauma (EURMAT) in children: a multicenter and prospective study

OBJECTIVE

The aim of this study is to present and discuss the results of a European multicentre prospective study about pediatric maxillofacial trauma epidemiology during a year.

STUDY DESIGN

The following data were recorded: gender, age, etiology, site of fracture, date of injury. Of the 3396 patients with maxillofacial fractures admitted within the study period, 114 (3.3%) were children aged 15 years and younger, with a male/female ratio of 2.6:1. Mean age was 10.9 years. Most patients (63%) were aged 11-15 years.

RESULTS

The most frequent cause of injury was fall (36 patients). Sport injuries and assaults were almost limited to the oldest group, whereas falls were more uniformly distributed in the 3 groups. The most frequently observed fracture involved the mandible with 47 fractures. In particular, 18 condylar fractures were recorded, followed by 12 body fractures.

CONCLUSIONS

Falls can be acknowledged as the most important cause of facial trauma during the first years of life. The high incidence of sport accidents after 10 years may be a reason to increase the use of mouthguards and other protective equipment. Finally, the mandible (and in particular the condyle) was confirmed as the most frequent fracture site.

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.

Interventions for the management of mandibular fractures

BACKGROUND

Fractures of the mandible (lower jaw) are a common occurrence and usually related to interpersonal violence or road traffic accidents. Mandibular fractures may be treated using open (surgical) and closed (non-surgical) techniques. Fracture sites are immobilized with intermaxillary fixation (IMF) or other external or internal devices (i.e. plates and screws) to allow bone healing. Various techniques have been used, however uncertainty exists with respect to the specific indications for each approach.

OBJECTIVES

The objective of this review is to provide reliable evidence of the effects of any interventions either open (surgical) or closed (non-surgical) that can be used in the management of mandibular fractures, excluding the condyles, in adult patients.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 28 February 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 1), MEDLINE via OVID (1950 to 28 February 2013), EMBASE via OVID (1980 to 28 February 2013), metaRegister of Controlled Trials (to 7 April 2013), ClinicalTrials.gov (to 7 April 2013) and the WHO International Clinical Trials Registry Platform (to 7 April 2013). The reference lists of all trials identified were checked for further studies. There were no restrictions regarding language or date of publication.

SELECTION CRITERIA

Randomised controlled trials evaluating the management of mandibular fractures without condylar involvement. Any studies that compared different treatment approaches were included.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trial quality and extracted data. Results were to be expressed as random-effects models using mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals. Heterogeneity was to be investigated to include both clinical and methodological factors.

MAIN RESULTS

Twelve studies, assessed as high (six) and unclear (six) risk of bias, comprising 689 participants (830 fractures), were included. Interventions examined different plate materials and morphology; use of one or two lag screws; microplate versus miniplate; early and delayed mobilization; eyelet wires versus Rapid IMF™ and the management of angle fractures with intraoral access alone or combined with a transbuccal approach. Patient-oriented outcomes were largely ignored and post-operative pain scores were inadequately reported. Unfortunately, only one or two trials with small sample sizes were conducted for each comparison and outcome. Our results and conclusions should therefore be interpreted with caution. We were able to pool the results for two comparisons assessing one outcome. Pooled data from two studies comparing two miniplates versus one miniplate revealed no significant difference in the risk of post-operative infection of surgical site (risk ratio (RR) 1.32, 95% CI 0.41 to 4.22, P = 0.64, I(2) = 0%). Similarly, no difference in post-operative infection between the use of two 3-dimensional (3D) and standard (2D) miniplates was determined (RR 1.26, 95% CI 0.19 to 8.13, P = 0.81, I(2) = 27%). The included studies involved a small number of participants with a low number of events.

AUTHORS' CONCLUSIONS

This review illustrates that there is currently inadequate evidence to support the effectiveness of a single approach in the management of mandibular fractures without condylar involvement. The lack of high quality evidence may be explained by clinical diversity, variability in assessment tools used and difficulty in grading outcomes with existing measurement tools. Until high level evidence is available, treatment decisions should continue to be based on the clinician's prior experience and the individual circumstances.

Maxillofacial Fractures. Analysis of demographic distribution and treatment in 2901patients (25-year experience)

INTRODUCTION

The aim of this study was to analyse retrospectively the demographic distribution, treatment modalities, and complications of maxillofacial fractures in 2901 patients treated in this department in Southeast Anatolia between 1978 and 2002. In addition, the use of internal fixation was evaluated in an effort to determine whether there were changes in using internal fixation techniques.

PATIENTS AND METHODS

Two thousand nine hundred and one cases of facial trauma were assessed according to age, sex, and aetiology, in addition to the distribution of the fractures relating to facial bones and seasons.

RESULTS

It was found that facial fractures were most frequent in males (77.5%) and in the 0-10 year age group; they tended to be more frequent during summer (36.3%); and traffic accidents were the most common aetiological factor (38%). 77.9% of cases were treated with conservative methods, and 22.1% with one or more internal fixation techniques. The most favoured technique was miniplate osteosynthesis; the complication rate associated with internal fixation was 5.7%.

CONCLUSION

Currently there are many techniques to be used in treating maxillofacial trauma. However, the experience of the surgical team is also an important factor in achieving satisfactory functional and aesthetic results, and in minimizing complications.

Transoral versus extraoral reduction of mandible fractures: a comparison of complication rates and other factors

OBJECTIVE

This retrospective study evaluates results and complications of the transoral and extraoral approaches for open reduction and internal fixation of mandibular body, angle, and ramus fractures. Our aim was to describe advantages and disadvantages of the techniques and to develop criteria for choosing between surgical approaches.

STUDY DESIGN AND SETTING

A retrospective chart review was performed on patients with mandible fractures occurring between August 1999 and October 2001 at a level I trauma center. Only mandibular body, angle, and ramus fractures requiring open reduction were selected for this study. Cases were evaluated for cause, age, gender, dentition, site and extent of fractures, surgical approach, postoperative complications, operative time, and postoperative occlusion.

RESULTS

Of the 227 patients with mandibular fractures, 78 had body, angle, or ramus fractures requiring open reduction. Of these, 36 were treated extraorally, and 42 were treated transorally. Criteria for selecting one procedure over another often involved training and surgeon experience and those factors normally considered important in defining the difficulty of treatment and prognosis of the patient. Seven of the 42 patients were converted from a transoral to an extraoral approach because of inadequate exposure. Similar complication rates occurred for the transoral and extraoral approaches, but because of the time required for converting from the transoral to extraoral approach, the average operative time was found to be increased in patients undergoing the transoral approach.

CONCLUSION AND SIGNIFICANCE

Decisions regarding treatment approaches for open reduction of mandible fractures often relate to surgeon experience and training, modified by factors that can affect uncomplicated healing such as fracture locations and displacement, comminution of the fracture, infection, dentition, and atrophic changes of the mandible. In some cases, the choice is affected by availability of equipment and experience of operating room personnel. More difficult cases involving an edentulous, atrophic mandible or comminution should be considered for extraoral exposure.

Complication rates associated with different treatments for mandibular fractures

PURPOSE

This study compared the complication rate with different types of mandibular fracture treatment (maxillomandibular fixation, 2-mm miniplates, 2.4-mm AO plates, and 2.7-mm AO plates).

PATIENTS AND METHODS

A total of 245 patients who presented with 386 fractures were retrospectively analyzed. Patient characteristics, type of fracture, severity of fracture, type of treatment used, and occurrence of complications were recorded. Statistical analysis was used to compare complication rates, fracture severity, and type of treatment.

RESULTS

There were no differences in the complication rates for the different types of treatment. There was a significant correlation (P < .05) between fracture severity and the overall complication rate, postoperative infection, and postoperative malocclusion, but there was no significant correlation between these complications and the type of treatment applied.

CONCLUSION

The occurrence of postoperative complications in the treatment of mandibular fractures is fundamentally related to the severity of the fracture rather than to the type of treatment used.

An audit of mandibular fractures treated by intermaxillary fixation, intraosseous wiring and compression plating

As the principles of rigid internal fixation and compression osteosynthesis were adopted by maxillofacial surgeons during recent years the time-honoured methods of intermaxillary fixation and intraosseous wiring have gradually been abandoned. We have reviewed our cases of mandibular fractures operated on in recent years and the changing trends in treatment.