A comparative study between transbuccal and extra-oral approaches in treatment of mandibular fractures

Comparison of bite force evaluation for mandibular angle fracture fixation by conventional miniplates versus new design miniplates: a clinical study

PURPOSE

To evaluate postoperative masticatory efficacy of a new design non-compression titanium miniplate compared to conventional non-compression titanium miniplate on the basis of bite force for treatment of mandibular angle fractures.

METHODOLOGY

The prospective study included 20 patients with mandibular angle fractures randomly categorized into 2 groups: Group I, fixation of angle fractures by conventional miniplates, and Group II, fixation of angle fractures by new design miniplates. Evaluation was done for clinical outcome, primarily bite force; radiological outcome; and associated postoperative morbidities at different time intervals.

RESULTS

The results showed to be highly significant in terms of mean operating time for plate adaptation and fixation and bite force adaptation (p = 0.003 at follow-up of 6 months) for the newer miniplate compared to the conventional miniplate. No statistically significant difference was seen for postoperative paresthesia, malunion, non-union, occlusal discrepancy, or hardware failure.

CONCLUSION

Within the limits of the study, it appears that the single, monocortical, non-compression, superior border new design miniplate proved to be a successful procedure for treating non-comminuted mandibular angle fractures specifically in terms of enhanced postoperative masticatory efficiency as compared to conventional miniplates. Further clinical studies with larger sample size can derive a more comprehensive conclusion.

Clinical Outcomes of ULTRA EZY Bar vs Erich Arch Bar in Conservative Management of Maxillofacial Fractures: A Randomized Controlled Trial

Objective

Various techniques have been employed from time to time to achieve maxillomandibular fixation, and arch bars provide an effective and versatile means of maxillomandibular fixation, and however, some of the issues occurring with it have been eliminated with the introduction of Ultralock EZY bar. The aim of the present study is to compare the advantages and disadvantages of Ultralock Ezy bar over the Erich arch bar in mid-face fracture or maxillary fracture or mandibular fracture or both requiring conservative treatment.

Materials and Methods

A total of 20 patients reported to the Department of Oral and Maxillofacial Surgery in Sudha Rustagi Dental College and Hospital, Faridabad, with mid-face fracture/maxillary fracture, mandibular fracture or both. The treatment plan required intermaxillary fixation. As a part of treatment plan, group was selected randomly divided into 20 arches in each group that is test arch group and control arch group.Test arch group included arches in which Ultralock EZY bar was done. Control arch group included arches in which Erich arch bar was done. The parameters compared in both the groups were surgical time taken, injuries due to wires, arch bar stability, oral hygiene index, patient acceptance and comfort, pulp vitality, and complication (if any).

Results

The average surgical time taken was less, and oral hygiene status and patient acceptance were better in test group. There was not much statistically significant difference in pulp vitality but number of cases with absence of pulp vitality were more in test group.

Conclusion

This study emphasizes the use of Ultralock Ezy bar as a quick and easy method than Erich arch bar. Oral hygiene maintenance was comparatively better in patients with Ultralock Ezy bar than those with Erich arch bar. For the patients who require long-term IMF, Ultralock Ezy bars can be a viable option.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12663-022-01821-3.

Comparison of Conventional Versus Right Angled Fixation Technique in Management of Mandibular Angle Fractures - A Prospective Randomized Clinical Study

PURPOSE

The treatment of mandibular angle fractures ranges from observation to closed reduction with maxillomandibular fixation to open reduction and internal fixation. The study aims to compare the effectiveness of three different techniques (transoral, transbuccal, and right-angled fixation technique) for single adaptational monocortical upper border plating in mandibular angle fracture.

METHODS

The study conducted at our center was a prospective randomized study. The study duration was from November 2019 to August 2021. The three groups included in our study were transoral, transbuccal, and transoral approach using the right-angled drill. Patients who required open reduction and internal fixation of mandibular angle fracture were included in the study. Computer-generated randomization method was used to allot the participants in any of the three groups, ie, transoral, transbuccal, or right-angled fixation technique. The primary outcome clinical variables were mouth opening (MO), occlusion stability, scar or laceration, facial nerve weakness, infection, and the radiological variables were gap between the fracture segments and displacement of the fracture segment. The secondary outcome of our study is a comparison of the perioperative complications including plate exposure during the entire fracture healing period. The covariates of the study were age, sex, etiology, and tooth in line of fracture. Statistical analysis was done using ANOVA, post hoc Tukey test, and Pearson χ² test. A P value less than 0.05 was considered statistically significant.

RESULTS

A total of 48 patients were included in our study. According to randomization, each group was allotted 16 patients. In the study, 66.7% of the study population were male and 33.3% were female; 75% of the study population were victims of road traffic accidents, and 25% were injured due to assault. The mean and standard deviation for MO at 1 month were 31.3 ± 2.9 for the transoral group, 35.8 ± 1.7 for the transbuccal group, and 35.5 ± 1.3 for the right-angled fixation group. On intergroup comparison, statistically significant results were seen at the 1-month postoperative MO clinical parameter. The P value here was 0.02 which was statistically significant.

CONCLUSION

The comparison of the right-angled fixation technique to transoral and transbuccal fixation methods have not been documented. Our study is the first of its kind to compare the right-angled fixation technique to various other approaches. Our study showed that the MO was better postoperatively with the transbuccal approach. The other variables showed no difference among the three techniques.

A Comparative Evaluation of Transbuccal versus Transoral Approach for the Management of Mandibular Angle Fractures: A Prospective, Clinical, and Radiographic Study

INTRODUCTION

In the facial bones, the angle of the mandible is the common site of fractures. Furthermore, it is the site with the highest number of complications after fracture and hence needs an efficient fixation. The right approach is still debatable for the angle fractures. In the light of these factors, we evaluated the transoral and the transbuccal approaches for the treatment of fractures at the angle of the mandible.

MATERIALS AND METHODS

Twenty patients were equally divided into two groups of transoral and transbuccal methods. The parameters such as ease of access, surgical time, occlusion, postsurgical infection, fracture gaps, scarring, and complications were noted, and the values that were compared were statistically analyzed. P < 0.05 was considered statistically significant.

RESULTS

No significant variations were seen in the variables such as ease of access, occlusion, postsurgical infection, and fracture gaps. Surgical time was significantly less for the transoral method. Negligible scarring was noted in the transbuccal method.

CONCLUSION

Although both the methods were comparable, the transbuccal approach was more efficient for the mandibular angular fracture treatment.

Transbuccal Approach in Management of Mandible Angle Fracture

With expanding dimensions and an eminent member of trauma team many Ear Nose Throat specialists are exposed to Oro-maxillofacial trauma. Mandibular angle is a difficult region to operate owing to its unique anatomy. Anglefractures form around 30-40% of the mandibular fracture. Open reduction and internal plating is the management of choice in most angle fractures and various approaches have been described in literature. We conducted a study of trans-buccal approach for management of mandibular angle fractures. It was a non-randomised observational study. 57 patients of mandible angle fractures were included in the study. The ORIF was done in these pts under general anaesthesia after careful surgical planning using trans-buccal approach. This approach included an intraoral exposure with stab incision for the trans-buccal passage of drill and screw diver. Out of 57 cases in our study 33 were males and 24 were females. 23/57 patients were in age group 25-35 years whereas 19/57 patients were in age group 15-25 years All 57 patients had good fracture healing. Occlusion dysfunction was seen in only 1 case. Infection was seen 3 cases while intraoral exposure of plates occurred in 2 cases. Average mouth opening was 43.3 mm at 6 weeks with progressive improvement on follow up. Extraoral scar healed well with very good cosmesis in all cases. We strongly suggest the use of transbuccal approach for ORIF in mandibular angle fractures owing to the ease of procedure, comfort of surgeon and less complication rate.

Complications and Reoperations in Mandibular Angle Fractures

IMPORTANCE

Mandible angle fractures can be repaired in a variety of ways, with no consensus on the outcomes of complications and reoperation rates.

OBJECTIVES

To analyze patient, injury, and surgical factors, including approach to the angle and plating technique, associated with postoperative complications, as well as the rate of reoperation with regard to mandible angle fractures.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study analyzing the surgical outcomes of patients with mandible angle fractures between January 1, 2000, and December 31, 2015, who underwent open reduction and internal fixation. Patients were eligible if they were aged 18 years or older, had 3 or less mandible fractures with 1 involving the mandibular angle, and had adequate follow-up data. Patients with comminuted angle fractures, bilateral angle fractures, and multiple surgical approaches were excluded. A total of 135 patients were included in the study. All procedures were conducted at a single, large academic hospital located in an urban setting.

MAIN OUTCOMES AND MEASURES

Major complications and reoperation rates. Major complications included in this study were nonunion, malunion, severe malocclusion, severe infection, and exposed hardware.

RESULTS

Of 135 patients 113 (83.7%) were men; median age was 29 years (range, 18-82 years). Eighty-seven patients (64.4%) underwent the transcervical approach and 48 patients (35.6%) received the transoral approach. Fifteen (17.2%) patients in the transcervical group and 9 (18.8%) patients in the transoral group experienced major complications (difference, 1%; 95% CI, -8% to 10%). Thirteen (14.9%) patients in the transcervical group and 8 (16.7%) patients in the transoral group underwent reoperations (difference, 2%; 95% CI, -13% to 17%). Active smoking had a significant effect on the rate of major complications (odds ratio, 4.04; 95% CI, 1.07 to 15.34; P = .04).

CONCLUSIONS AND RELEVANCE

During repair of noncomminuted mandibular angle fractures, both of the commonly used approaches-transcervical and transoral-can be used during treatment with equal rates of complication and risk of reoperation. For a patient undergoing surgery for mandibular angle fracture, smoking status is more likely to predict surgical outcomes rather than how the surgeon chooses to approach and fixate the fracture.

LEVEL OF EVIDENCE

3.

A Comparative Study of Transbuccal and Extraoral Approaches in the Management of Mandibular Angle Fractures: A Systematic Review

AIM

The aim of the present study was to compare the extraoral and transbuccal approaches for the treatment of mandibular angle fractures with regard to postoperative complications.

PATIENTS AND METHODS

An electronic search for relevant articles without language and date restrictions was performed in July 2016. Inclusion criteria were studies in humans including randomised controlled trials (RCTs), controlled clinical trials (CCTs), prospective studies (PS), and retrospective studies (RS). In total, 107 patients were included from four studies (transbuccal = 48, extraoral = 59). The follow-up period varied from 3 months to 24 months.

RESULTS

In extraoral group the average of unsightly scar, facial nerve weakness, infection, malocclusion, plate removal were found to be 55% (range, 10% -100%), 26.5% (range, 0%-53%), 11.7% (range, 0% - 20%), 22.5% (range, 0% -50%), 6.7% (range, 3.3% - 10%) respectively while these parameters in the transbuccal approach were found to be no obvious unsightly scar, 6.6 % (range, 0%-13.3%), 8.1% (range, 0% - 20%), 4.8% (range, 0% - 12.5%), 0%. The incidence of postoperative trismus and nonunion/malunion were 0% in both groups.

CONCLUSION

The results of this study suggest that transbuccal approach shows fewer complications than extraoral approach when used for the treatment of mandibular angle fractures.

Comparison of Management of Mandibular Angle Fractures by Three Approaches

BACKGROUND AND OBJECTIVES

Various methods have been reported in the literature for treating mandibular angle fractures comparing extra oral, intra oral and transbuccal approaches for achieving the goals of restoration of anatomic form, maintenance of segment position and bony union.

MATERIALS AND METHODS

This study was conducted to assess the simple and effective surgical approach in treating mandibular angle fractures and the outcome by means of three approaches i.e. intra oral, transbuccal and extra oral approaches.

RESULTS/CONCLUSION

A total of 45 patients with mandibular angle fracture were divided into three groups. Group I-intra oral approach-15 patients, Group II-transbuccal with intraoral approach-15 patients, Group III-extra oral approach-15 patients. The results of our study found intraoral approach to be much better because it is simple, precise, duration is short, and post operative complications are less with minimal morbidity and pain.

Outcome of comminuted mandibular fracture repair using an intraoral approach for osteosynthesis

PURPOSE

Traditionally, the treatment of comminuted mandibular fractures involves both closed and open reduction. However, modern treatment principles increasingly tend toward open reduction and internal fixation to shorten oro-functional rehabilitation. Although this method increasingly gained popularity to date, a controversy regarding the extraoral versus the intraoral surgical approach still exists. The current study aimed to objectively evaluate the outcome of comminuted mandibular fracture treatment involving open reduction and internal fixation using an intraoral approach.

PATIENTS AND METHODS

Consecutive patients treated at the Department of Cranio-Maxillofacial and Oral Surgery, University Hospital of Zurich, between 2005 and 2012 were included. Demographic, presurgical, perisurgical, and postsurgical data were tabulated and statistically evaluated using the χ test and the Mann-Whitney U test.

RESULTS

Forty-five patients could be included. Excellent postoperative results were seen in 84% (38 patients) of the total cohort. Postoperative complications were seen in 16% (7 patients). These 7 patients had the following complications: wound dehiscence (7% [n = 3]), osteomyelitis (7% [n = 3]), abscess development (4% [n = 2]), bone necrosis (2% [n = 1]), and severe nonocclusion (2% [n = 1]).

CONCLUSION

Present data showed that the intraoral approach for open reduction and internal fixation in comminuted mandibular fractures represents a comparable surgical technique regarding fracture repositioning and occlusal rehabilitation. Considerably, the risk of concomitant neurovascular damage or even facial scarring, as demonstrated in the extraoral approach, can be neglected by using this technique. Nevertheless, each case has to be judged on its own accord as to which technique can best treat the underlying fracture.

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.

Determination of a safety zone for transbuccal trocar placement: an anatomical study

The identification of a safe and accurate technique for facial incisions for transbuccal approaches to the mandibular angle fractures remains a challenge. An alternative method of safely and accurately placing the buccal skin incision is described in this cadaveric study. Thirty-two dissections were performed on 16 bilateral embalmed adult cadaveric heads. In order to identify a safety zone for transbuccal trocar placement, a triangle shaped zone created by three lines was determined. The branches of the facial nerve in this zone were reflected by sharp and blunt dissections. Of 32 sides, marginal mandibular branch was encountered in 1 and marginal mandibular branch and buccal branch of the facial nerve were found in 2 of the predetermined triangle. In 29 of 32 specimens, the marginal mandibular branch was encountered out of the triangle and deep to the platysma muscles. The triangle determined in the present anatomosurgical study presents an easy identifiable and safe zone for trocar placement.