Accuracy and outcome of mandibular fracture reduction without and with an aid of a repositioning forceps

Transbuccal vs. Intraoral Approach using an Angulated Screwdriver in Fixation of a Mandibular Angle Fracture

Objectives:

This study aimed to evaluate surgical stability and cosmetic outcomes in patients with mandibular angle fractures (MAFs) using an angled screwdriver (ASD) versus transbuccal trocar (TBT) for single locking plate fixation.

Methods:

A prospective cohort clinical study was done on 44 male patients (88%) and 6 (12% females patients with MAFs, categorized into 2 groups. Group A patients were treated with strictly intraoral vestibular incision using an angulated screwdriver; group B was treated with TBT. Both groups placed a single locking 2.0 mm mini-plates at the inferior border. The main outcome variables were the perioperative complication rate.

Results:

There were no statistical differences between both groups regarding postoperative wound dehiscence, screw or/and plate looseness, infection rate, and inferior dental nerve injury. The study (ASD) approach took 28.10±3.3minutes, while the TBT approach took 37.40±1.75minutes, indicating a highly significant difference in operating time (P=0.001). Post-operative edema had decreased significantly in the ASD group.

Conclusion:

According to the present results, a strictly intraoral approach for ASD enabled stable fixation of MAFs using a single mini-locking plate. This can significantly reduce operation time and postoperative edema and prevent extraoral scarring.

An approach for simultaneous reduction and fixation of mandibular fractures

This article presents a new approach for the design of a flexible V-shaped miniplate for mandibular fractures, which combines simultaneous fracture reduction and fixation. A Computerized Tomography (CT) based finite element model was developed to assess the reliability of this design. Muscle and mastication forces were included to replicate post-surgery loading. The V-plate is compared with a standard, linear miniplate, typically used for mandibular fixation. The results indicate that the proposed design can support the fracture while inducing limited fracture displacement, in addition to reducing the duration of the surgery due to fracture reduction by tightening the wire.

Is manual reduction adequate for intraoperative control of occlusion during fixation of mandibular fractures? A systematic review and meta-analysis

The aim of this systematic review was to find out if manual intraoperative control of occlusion is adequate for the reduction of mandibular fractures in comparison with intermaxillary fixation (IMF). We searched PubMed, Embase, the Cochrane Library and Clinical Trials Registry, and the references of included trials. Our primary outcomes of interest were the reduction of fracture anatomically and radiographically, occlusal disturbances, and the incidence of revision procedures due to poor occlusion or reduction. Our secondary outcomes of interest were operating time and infective complications. Of the 257 studies retrieved (manual reduction = 136, IMF = 121), four were included. The studies had an unclear risk of bias. Nevertheless, the overall effect was statistically significant and in favour of manual reduction, with a lower number of adverse events in the manual reduction group (n = 43) than in the IMF group (n = 78), odds ratio 0.42 (95% CI 0.27 to 0.64). An absolute reduction in adverse events was seen in occlusion disturbances (120 fewer/1000), revision procedures (164 fewer/1000), and infective complications (178 fewer/1000). The evidence to support manual reduction over IMF for the intraoperative control of fracture fragments and occlusion was derived from few studies with an unclear risk of bias, and the quality was low. The results were not different when condylar fractures were present. The overall certainty of evidence was moderate. Clinicians should select the appropriate technique based on the injury pattern, and the treating surgeon's experience and available resources.

A new classification of mandibular fractures

There is no accepted method of reporting mandibular fracture that reflects incidence, treatment and outcome for individual cases. As most series include anatomical site only for all fractures, the aim was to establish a new method to report fractures based on a systematic review of the literature and an internal audit. The classification proposed is: Class I; condyle, II; angle, IIc; II+condyle, III; body/symphysis, IIIc; III+condyle, IV; multiple fractures not including condyle, IVc; IV+condyle, V; bilateral condyle±other fracture(s). A total of 10,971 adult and 914 paediatric cases were analyzed through systematic review, and 833 from the regional audit. Only 32% (14/44) of reported series could be reclassified which, when added to the audit data, showed Class IV was most common (29%), with similar proportions of Class III, Class IIIc and Class II (18-23%). External validation (literature review) in terms of treatment and outcome was non-informative, but the internal validation (audit) demonstrated an increasing requirement for adding maxillomandibular fixation (MMF) to open reduction and internal fixation (ORIF) as class increased. The heterogeneity of data reporting found in the systematic review confirms the need for a classification such as this, likely to enhance comparison of varying management protocols.