OPEN REDUCTION AND INTERNAL FIXATION OF COMBINED ANGLE AND BODY/SYMPHYSISFRACTURES OF THE MANDIBLE: HOW MUCH FIXATION IS ENOUGH? ellis article JOMS

1. Edward Ellis III J Oral Maxillofacial Surgery 71:726-733, 2013

2. INTRODUCTION
 Bilateral fractures occur in over half of the patients who present with mandibular
fractures.
 The most common mandibular fracture seen is an angle fracture combined with a
contralateral fracture of the mandibular body or symphysis.
 The management of mandibular fractures has changed from intermaxillary fixation
(IMF) with or without internal wire fixation to internal plate and/or screw fixation
and no IMF.
 While the use of plate and/or screw fixation has potential benefits for the patient,
complications are not uncommon.

3.  Rigid internal fixation is a term applied to the application of sufficient internal
hardware to prevent movement across the fracture site when normal
functional forces are in effect.
 Examples of rigid internal fixation include locking/nonlocking reconstruction
bone plates, multiple bone plates at the fracture site, single strong non-
reconstruction bone plates, or multiple lag screws.
 To prevent interfragmentary motion during function and allow primary
osseous union to proceed.
Rigid Fixation

4.  Anything less than rigid is, by definition, nonrigid.
 Functionally stable fixation is not rigid fixation but is the application of various
hardware schemes which do not prevent micro-motion across the fracture site
during function, but permit healing of the fracture by secondary bone healing
(with formation of callous) and without IMF.
 Examples :titanium miniplate for an angle fracture (Champy technique) or a
single titanium miniplate for body or symphysis fracture.
Non -Rigid Fixation

5. AIM OF STUDY
To assess the internal fixation requirements for
combined mandibular angle and contralateral
body or symphysis fracture of the mandible
To examine a large sample of patients treated
with rigid or non-rigid fixation for this common
mandibular fracture.

6. PATIENTS AND METHODS

7. INCLUSION CRITERIA
I. Age > 15 years.
II. Simple (linear) fractures through the angle and the contralateral body or
symphysis
III. Neither fracture was grossly infected at time of treatment.
IV. Open reduction and internal fixation (ORIF) of the angle fracture
through intraoral approach and application of a single 2 mm Titanium
miniplate (1 mm thick) along the superior border (Champy’s
technique).
V. ORIF of contralateral body or symphysis fracture through a transoral
approach using a variety of plate and/or screw techniques.
VI. No postoperative IMF.
VII. 6-12 weeks of follow-up.

8. EXCLUSION CRITERIA
I. Presence of gross infection of either fracture.
II. Cases with insufficient records.
III. Patient’s Irregular follow-ups.

9. DURATION : July 1, 1993 through December 31, 2012
GENERAL DEMOGRAPHIC INFORMATION : gender , age , cause , etc
 Location of angle fractures (ie, left versus right)
 Site of body or symphysis fracture.
 Presence of a tooth in the line of the fractures
 Extraction of tooth in line of fracture.
 Internal fixation techniques for the body or symphysis fracture.
 Occlusal relationship at last follow-up visit.
 Major postsurgical complications, which were defined as a need
for further surgical intervention.
• Simple wound care ( prescriptions + antibiotics)
• Use of elastics for slight malocclusion was not considered as
major complication.

11. RIGID GROUP
1) At least two 2.4-mm lag screws with an arch bar.
2) One 2.4-mm compression plate with an arch bar.
3) Two 2-mm non-compression locking or non-locking mini-
plates (1 mm thick) with an arch bar.
4) One 2-mm locking mandibular bone plate (all are thicker
and much stronger than standard 1-mm-thick mini-plates) with
or without a second plate and an arch bar.
5) A non-locking 2.7-mm or locking 2.4-mm reconstruction
bone plate with or without an arch bar.

12. 2 2.4mm LAG SCREWS
2.4-MM DYNAMIC COMPRESSION PLATE

13. TWO 2-mm MINIPLATES (1mm THICK)
2mm LOCKING PLATE

14. 2.4-MM RECONSTRUCTION BONE PLATE
2-mm LOCKING PLATE WITH A SMALLER , THINNER MINIPLATE
PLACED ABOVE IT

15. NON-RIGID GROUP
A SINGLE 2mm MINIPLATE (1-mm THICK) APPLIED
TO BOTH FRACTURES

16. ANALYSIS
The 2 groups were compared for differences in demographic characteristics
using
• χ 2 cross-table analysis for discontinuous variables or Student
• t test for continuous variables.
Outcomes for the 2 groups were similarly analyzed.

17. RESULTS

18. TOTAL
MEAN AGE
GROUP
AGE RANGE
MALES
LEFT SIDED
ANGLE FRACTURE
RIGID
976
22.2YRS
15-59YRS
893
644
NON-
RIGID
149
28.4YRS
16-54
134
101

19. RIGID NON-RIGID
Altercations 879 129
Motor vehicle accidents 49 8
Falls 34 8
Others 14 4
879
129
49 834 814 4
Altercations Motor vehicle accidents Falls Others

21. COMPLICATIONS

22. 36
12
TOTAL COMPLICATION = 48 (4.9%)
8= WOUND PROBLEMS
(dehiscence of the
incision and exposure of
the wound plate)
4 = INFECTIONS
IN RIGID FIXATION

23. ALL WOUND PROBLEMS
36
19 = INFECTION
(n=7) Abscess formation
(n=8) Drainage of purulent
matter intraorally
(n=4) Drainage of purulent
matter extraorally
19 underwent incision and
drainage
(n=13) Intraoral approach
(n=6) Extraoral approach
15 = IMMEDIATE OR SUBSEQUENT
HARDWARE REMOVAL
4 = no bony union
1 = bone grafting required after 4
months

24. ALL WOUND PROBLEMS
36
17 = NON-INFECTED WOUND
PROBLEMS
 granulation tissue around the
incision site
 plate /bone exposure
 7 = loose hardware
 4 = fracture not united

25. TOTAL COMPLICATION = 23 (15.4%)
22= WOUND PROBLEMS
8 = Angle fracture site
2 = Body site
4 = Both sites
IN NON-RIGID FIXATION
14 = NON-INFECTED WOUND
PROBLEMS
 granulation tissue around the
incision site
 plate /bone exposure
 9 = loose hardware

26. TOTAL COMPLICATION = 23 (15.4%)
IN NON-RIGID FIXATION
IMMEDIATE OR SUBSEQUENT
HARDWARE / NON VITAL BONE
REMOVAL (transoral approach)
8 = fracture has healed
6 = mobility present
8 = INFECTION
(n=4) Abscess formation without
drainage
(n=5) Drainage of purulent matter
through incision site
7 ANGLE
1 BODY
7= Hardware removal
3= Mobility

27. MALOCCLUSION
 1 CASE OF MALOCCLUSION REQUIRED SECONDARY INTERVENTION
 AFTER 4 WEEKS POST OPERATIVELY
 IN-LINE DEFORMATION OF BONE PLATE APPLIED TO BODY/
SYMPHYSIS REGION

28. DISCUSSION

29.  Studies have reported that when treating mandibular fractures,
rigid fixation is not always necessary, and there are multiple
functionally stable hardware constructs that result in healing and
excellent postoperative results.
 Statistically significant difference in the major complication rate
between the rigid and nonrigid groups (P < .001).
 The results of this study show a significantly higher rate of wound
problems when both fractures are treated with nonrigid fixation.
 This indicates that although nonrigid forms of fixation may work
on isolated (single) fractures of the mandible, they might not be
reliable when used on more than one fracture of the mandible.

34. PITFALLS
– Only simple linear # were included
– Relationship with # pattern were not studied
– The word slight malocclusion was not defined
– Rigid group 976; nonrigid group 149
– Very small sample size of non rigid group
HIGHLIGHTS
• Large study population
• First article of its kind

35. CONCLUSION
The fixation requirements of patients treated with double fractures of the
mandible are different than when treating isolated fractures of the mandible.
Double fractures require that at least one of the fractures undergoes rigid fixation
to decrease the incidence of complications.