Macroplate fixation of fractures of the edentulous atrophic mandible: immediate function and masticatory rehabilitation

Mandibular reconstruction after post-traumatic complex fracture: Comparison analysis between traditional and virtually planned surgery

BACKGROUND

Jaw reconstruction after complex post-traumatic fracture is still a challenge for surgeons using traditional surgery. Virtual surgical planning has proven to be a valid tool for managing these fractures. The aim of this study is to quantitatively evaluate the VSP effectiveness compared to traditional surgery in the management of complex mandibular fractures.

METHODS

30 patients with diagnosis of complex mandibular fracture were enrolled and divided in two groups: Group A (virtually planned surgery), The plate was pre-modeled and employed during the surgery; Group B (traditional surgery), the plate was shaped directly during the surgery. Virtually planned and post-operative Computer Tomography were after compared for both the groups to highlight discrepancies in mm.

RESULTS

Fracture surgical reduction was successful without intraoperative complications. In Group A, all the mean discrepancies' values were <1 mm while in Group B the values were included between 1.36 and 1.94 mm. The mean operative time was 69 min for Group A, while 106 min for Group B.

CONCLUSIONS

Fracture virtual reduction and realization of pre-modeled plate are able to guarantee a more anatomically correct reduction and a decrease in operating times. These outcomes translate into a decrease in both short and long-term complications.

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.

Deep Circumflex Iliac Artery Flap Reconstruction in Brown Class I Defect of the Mandible Using a Three-Component Surgical Template System

BACKGROUND

Computer-assisted surgery is widely used in mandibular reconstruction, but the process is not well described for cases using the deep circumflex iliac artery flap (DCIA) as the donor site. This study aimed to present a DCIA-based three-component surgical template system (3-STS) in patients with a mandibular Brown class I defect.

METHODS

This retrospective cohort study compared clinical outcomes of mandibular reconstruction with DCIA flap using 3-STS or conventional surgical templates. The primary outcome of the study was the accuracy of reconstruction, and the secondary outcomes included surgical time and bone flap ischemia time. Surgery-related parameters and functional outcomes were also recorded and compared.

RESULTS

Forty-four patients (23 in the 3-STS group and 21 in the control group) between 2015 and 2021 were included. Compared with the control group, the 3-STS group had higher accuracy of reconstruction, indicated by lower deviation in absolute distance (1.45 ± 0.76 mm versus 2.02 ± 0.89 mm; P = 0.034), and less deviation in coronal and sagittal angles (0.86 ± 0.53 degree versus 1.27 ± 0.59 degrees, P = 0.039; and 2.52 ± 1.00 degrees versus 3.25 ± 1.25 versus, P = 0.047) between preoperative and postoperative computed tomographic imaging. Surgical time and bone flap ischemia time were significantly reduced in the 3-STS group compared with the control group (median time, 385 minutes versus 445 minutes and 32 minutes versus 53 minutes, respectively; P < 0.001). In addition, masseter attachment was preserved in the 3-STS group but not in the control group. No differences were found in adverse events or other clinical variables.

CONCLUSION

The 3-STS can improve accuracy, simplify intraoperative procedures to increase surgical efficiency, and preserve functionality in mandibular reconstruction for Brown class I defects.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Head & Neck Trauma in the Geriatric Population

Craniofacial trauma in the geriatric population is increasing as our population ages. Due to loss of bone quality and medical comorbidities, injuries for minor trauma can be severe. A more extensive medical evaluation is usually warranted in this population before proceeding with surgery. In addition, unique surgical considerations exist in the repair of atrophic and edentulous bony fractures. Some quality improvement measures have already been undertaken but more is needed to help standardize care in this vulnerable population.

Current Evidence for the Management of Edentulous Atrophic Mandible Fractures: A PRISMA-SWiM Guided Review

Study Design

PRISMA-SWiM guided systematic review.

Objective

1. Provide consistent evidence regarding the management of atrophic mandible fractures; 2. To search, evaluate and validate existing guidelines if any for the management; 3. Provide evidence regarding specific management of condylar fractures in the atrophic mandible; 4. To address the clinical applicability of bone grafts.

Methods

A systematic review was conducted using the PRISMA-SWiM protocol. PROSPERO ID: CRD42021235111. Studies with adequate data on outcome, treatment methods were selected. Isolated case reports, case series, and non-human studies were excluded. Quality assessment was done using Newcastle -Ottawa scale. The level of evidence was assessed using Oxford Level of Evidence.

Results

Mandibular body was the most common type of fracture. Self falls and RTA were the most common etiologies. Condylar fracture was most commonly managed conservatively with ORIF employed in few studies. For the mandible compression and non-compression osteosynthesis were used. Bone grafts were used in cases with segmental defects or cases requiring augmentation.

Conclusions

There is lack of proper evidence to definitely conclude any single treatment modality. However, the consensus is towards ORIF. Reconstruction plates are preferred by many authors. However, unilateral fractures may be managed by miniplates. Bilateral fractures require more rigid fixations. Open reduction and internal fixation of condylar fracture is indicated in cases with displacement or low-level fractures.

Comparing Load-Sharing Miniplate and Load-Bearing Plate Fixation in Atrophic Edentulous Mandibular Fractures: A Systematic Review and Meta-Analysis

PURPOSE

To critically examine reported data to compare patient outcomes between load-sharing and load-bearing plate fixation for edentulous mandibular fractures.

MATERIALS AND METHODS

A systematic review and meta-analysis were designed to test the null hypothesis of no difference in postoperative outcomes between load-sharing and load-bearing plate fixation in atrophic, edentulous mandibular fractures. The PubMed, EMBASE, Cochrane Library, Elsevier text mining tool database, and clinicaltrials.gov trial registries were queried up until July 2016. The quality of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation method.

RESULTS

A total of 1212 studies were screened for inclusion of which we included 1 high-quality Cochrane review, 6 narrative reviews, and 21 publications of case reports and case series. Overall, the quality of evidence was low. No difference was found between load-bearing and load-sharing fixation in functional recovery, nonunion, or infection. An uncontrolled case series portrayed complete functional and morphological restoration in 96.9% of patients (83.2-99.5; 95% confidence interval) in load-bearing osteosynthesis while another demonstrated the same outcome in only 40.0% of patients (17.5-65.0; 95% confidence interval).

CONCLUSIONS

The authors did not find a statistically significant difference between load-bearing and load-sharing plate fixation in edentulous atrophic mandibular fracture patients; although this finding may be influenced by type 2 statistical error. Surgeons should continue to use their best clinical judgment in deciding on treatment approach for these challenging fractures. Future studies with higher level evidence are necessary to guide optimal fracture management.

Implant-supported rehabilitation after treatment of atrophic mandibular fractures: report of two cases

OBJECTIVE

The objective of this article is to present options of rehabilitation with dental implants in two cases of severely atrophic mandibles (<10 mm) after rigid internal fixation of fractures.

PATIENTS AND METHOD

Two patients who sustained fractures in severely atrophic mandibles with less than 10 mm of bone height were treated by open reduction and internal fixation through a transcervical access. Internal fixation was obtained with 2.4-mm locking reconstruction plates. The first patient presented satisfactory bone height at the area between the mental foramens and after 2 years, received flapless guided implants in the anterior mandible and an immediate protocol prosthesis. The second patient received a tent pole iliac crest autogenous graft after 2 years of fracture treatment and immediate implants. After 5 months, a protocol prosthesis was installed in the second patient.

RESULTS

In both cases, the internal fixation followed AO principles for load-bearing osteosynthesis. Both prosthetic devices were Branemark protocol prosthesis. The mandibular reconstruction plates were not removed. Both patients are rehabilitated without complications and satisfied with esthetic and functional results.

CONCLUSION

With the current techniques of internal fixation, grafting, and guided implants, the treatment of atrophic mandible fractures can achieve very good results, which were previously not possible.

Treatment of edentulous mandibular fractures with rigid internal fixation: case series and literature review

The aim of the study is to analyze the effectiveness of rigid internal fixation (RIF) for treating edentulous mandibular fractures. Because of the low incidence of fractures in edentulous mandible, there is no consensus of the optimal treatment for it. This study included all edentulous patients with mandibular fracture diagnosis, who were treated with internal fixation at the Hospital Italiano de Buenos Aires from November 1991 to July 2011. Data such as age, gender, etiology and location of fracture, surgical approach, type of osteosynthesis used, and postoperative complications were analyzed. A total of 18 patients, 76.2 years mean age, 12 females (66.6%), presented a total of 35 mandibular fractures. The mandibular body was the most common localization of the fractures. Twenty-five fractures received surgical treatment with RIF, mainly approached extraorally. Reconstruction plates were the most common type of fixation used. Fracture reduction was considered satisfactory in 96.5%, with 22.2% of complications and 11.1% of reoperations needed. Open reduction and RIF demonstrated to be a reliable method for treating edentulous mandibular fractures. Nevertheless, there is lack of high-level recommendation publication to support this.

The role of the titanium functionally dynamic bridging plate for the treatment of the atrophic mandible fractures

The role of the titanium functionally dynamic bridging plate (TFDBP) in the fracture treatment of the severely atrophic mandible was assessed retrospectively. In 28 consecutive patients with fractures of a severely atrophic mandible fixation was carried out with TFDBPs. Twenty-one patients with 27 fractures were included in the study and then followed up for complications and the progress of fracture healing for 17 months postoperatively on average. There was only one case that required plate removal. All patients showed bone healing 3 months after surgery. The mental nerve sensation improved in 12 out of 23 fractures that had presented with nerve function disturbance. Every patient who had dentures prior to sustaining the fracture was able to return to denture wearing 3 weeks after surgery. No major complications occurred. A high proportion of bone healing with a low complication rate was observed with the use of TFDBPs in the treatment of severely atrophic mandible fractures. The TFDBP is an excellent alternative to conventional plating of the severely atrophic mandible.

Surgical treatment of the atrophic mandibular fractures by locked plates systems: our experience and a literature review

The management of atrophic mandibular fractures in edentulous patients represents an insidious issue for the maxillofacial surgeon due to the biological and biomechanical conditions that are unfavorable for fracture fixation and bone healing. The purpose of this study was to evaluate the results of the treatment of atrophic mandibular fractures and to compare the outcomes of different plating systems used for stabilization. We selected a study group of 16 patients with fractures of completely edentulous atrophic mandibles who were treated in our department between 2004 and 2010. All patients were surgically treated by open reduction and internal rigid fixation using 2.0-mm large-profile locking and 2.4-mm locking bone plates. All patients achieved a complete fracture healing and fast functional recovery of mandibular movements without intraoperative or postoperative surgical complications. The results of our study demonstrated the efficacy of this type of treatment in association with a low postoperative complication rate, a reduction in the recovery time, and the possibility to have an immediately functional rehabilitation. There were very similar results using each of the two bone plating methods considered: no case had hardware failure or nonunion of the fracture. The 2.0-mm large locking plate is thinner, exposes through the soft tissues less frequently, and is much easier to shape and adapt to the mandibular anatomy. However, the 2.4-mm locking plate system still represents the reference hardware in the condition of severe bone atrophy.