Intraosseous wire fixation versus rigid osseous fixation of mandibular fractures: a preliminary report

Comparative Evaluation of Clinical Outcome Including Neurosensory Deficit and Pain Score Variables Using Rigid Internal Fixation with Three-Dimensional Miniplate Internal Fixation in Simultaneous Angle and Contralateral Body/Parasymphysis Fractures of the Mandible: A Prospective, Randomized Controlled Study

Purpose  There have been numerous advancements in the strategies used for treating mandibular fractures in the present times, while open reduction and internal fixation is still accepted as the most preferred treatment option for such fractures despite numerous drawbacks. The aim of the present prospective, randomized controlled study was to evaluate the clinical outcome including neurosensory deficit and pain score variables in mandibular fractures that were treated using rigid internal fixation with three-dimensional (3D) miniplate internal fixation. Materials and Methods  For the present study, a total of 20 patients of either sex in an age range of 18 to 55 years with simultaneous angle and contralateral body/parasymphysis fractures of the mandible were included, while the clinical outcome was compared in relation to the two groups wherein different treatment options were used including using rigid internal fixation in one as against 3D miniplate internal fixation in the other. Results  Pairwise comparison of pain scores in Group I and Group II patients by the Mann-Whitney U-test at different time zones revealed the results to be statistically significant for all pairs except when the findings were compared between 1 month and 3 months after the procedure in Group II patients. Also, significant recovery was observed in both Group I and II patients during healing when assessed preoperatively to 1 month and then 3 months after the procedure with the results being statistically highly significant in case of the variations observed in relation to the neurosensory deficit observed at different time zones for both Group I and II patients ( p  = 0.0001). Conclusion  Based on the results obtained, it can be concluded that 3D miniplate-led osteosynthesis was found comparable to the osteosynthesis accomplished using reconstruction plates during fixation of unfavorable body/parasymphysis fractures of mandible in study, providing optimal stability, while satisfactorily meeting the biomechanical requirements for occlusal loading, and an early return to normal function.

No Reduction in Surgical Site Infection Obtained with Post-Operative Antibiotics in Facial Fractures, Regardless of Duration or Anatomic Location: A Systematic Review and Meta-Analysis

Background: We performed a systematic review of the literature on antibiotic prophylaxis practices in open reduction, and internal fixation of, facial fracture(s) (ORIFfx). We hypothesized that prolonged antibiotic prophylaxis (PAP) would not decrease the rate of surgical site infections (SSIs). Methods: We performed a systematic review of four databases: PubMed, CENTRAL, EMBase, and Web of Science, from inception through January 15, 2017. Three independent reviewers extracted fracture location (orbital, mid-face, mandible), antibiotic use, SSI incidence, and time from injury to surgery. Mantel-Haenszel and generalized estimating equations were carried out independently for each fracture zone. Results: Of the 587 articles identified, 54 underwent full-text review, yielding 27 studies that met our inclusion criteria. Of these, 16 studies (n = 2,316 patients) provided data for mandible fractures, four studies (n = 439) for mid-face fractures, and six studies (n = 377) for orbital fractures. Pooled analysis of each fracture type's SSI rate showed no statistically significant association with the odds ratio (OR) of developing an SSI. For mandible fractures treated with ORIFfx, the OR for an SSI after 24-72 hours of prophylaxis relative to <24 hours was 0.85 (95% confidence interval [CI] 0.62-1.17), whereas for >72 hours compared with <24 hours, the OR was 1.42 (95% CI) 0.96-2.11). For mid-face fractures, there was no improvement in SSI rate from PAP (OR 1.05; 95% CI 0.20-5.63). Conclusions: We did not demonstrate a lower rate of SSI associated with PAP for any ORIFfx repair. Post-operative antibiotics for >72 hours paradoxically may increase the SSI risk after mandible fracture repairs.

Post-traumatic and postoperative neurosensory deficits of the inferior alveolar nerve in mandibular fracture: a prospective study

Objectives

We evaluated and recorded post-traumatic and postoperative neurosensory deficits of the inferior alveolar nerve (IAN) in mandibular fracture in order to identify associated risk factors.

Materials and Methods

This was a prospective cohort study composed of 60 patients treated for mandibular fracture. The primary study variable was the change between the post-traumatic IAN neurosensory examination score and the score after fracture reduction. Risk factors were categorized as demographic, anatomic, fracture displacement, and treatment. Appropriate descriptive and bivariate statistics were computed.

Results

Sixty patients with unilateral mandibular fracture reported within 24 hours of injury were evaluated over a one-year period. A post-traumatic neurosensory deficit was observed in 52 patients (86.7%), the percentage of which was reduced to 23.3% over the follow-up period. Abnormal postoperative neurosensory scores were significantly higher in angle fracture cases (33.3%) compared to body fracture cases (11.1%). When recovered and non-recovered neurosensory scores were compared by fracture location, 88.9% of body fracture cases showed significant recovery compared to 66.7% of mandibular angle fracture cases. Cases with less than 5 mm fracture displacement showed statistically significantly higher neurosensory recovery scores (90.6%) compared to those with more than 5 mm fracture displacement (60.7%).

Conclusion

Use of a miniplate with mono-cortical screws does not play a role in increasing IAN post-traumatic neurosensory deficit. Early management can reduce the chances of permanent neurosensory deficit. Mandibular fracture displacement of 5 mm or more and fracture location were found to be associated with an increased risk of post-traumatic IAN neurosensory score worsening.

Controversies in the Management of the Trauma Patient

Facial trauma is a significant cause of morbidity in the United States. Despite the large volume of trauma surgeries at most academic institutions, there is still controversy regarding management of many traumatic injuries. The literature lacks clear-cut best practices for most fractures. In orbital trauma, there is debate about the optimal timing of repair, preferred biomaterial to be used, and the utility of evaluation afterward with intraoperative computed tomographic scan. In repair of mandible fractures, there is debate regarding open versus closed reduction of subcondylar fractures, or alternatively, endoscopic repair.

Fixation of mandibular angle fractures: clinical studies

PURPOSE

The purpose of this study was to review the literature regarding the evolution of current thoughts on fixation of mandibular angle fractures (MAFs).

METHODS

An electronic search in PubMed was undertaken in August 2012. The titles and abstracts from these results were read to identify studies within the selection criteria. Eligibility criteria included studies from the last 30 years (from 1983 onwards) reporting clinical studies of MAFs.

RESULTS

The search strategy initially identified 767 studies. The references from 1983 onwards totaled 727 articles. Fifty-four studies were identified without repetition within the selection criteria. Two articles showing significance in the development of treatment techniques were included. Additional hand-searching yielded 13 additional papers. Thus, a total of 69 studies were included.

CONCLUSIONS

Prospective randomized controlled studies of MAFs repair techniques are scarce. The available data at best predict that complications are associated with all kinds of fixation techniques. The similar results of complications in studies using different methods of fixation indicate that biomechanics are only one factor to be considered when treating MAFs. A second fracture in the mandible (which was observed in the majority of the studies' population) can confound the outcome data because the fixation requirements of a double fracture are often different from those for an isolated fracture. It can be necessary additional effort intended for increase of stability when using biodegradable plate system to fixate MAFs. The use of 1.3 mm malleable miniplates was associated with an unacceptable incidence of plate fracture, suggesting that this is not the most adequate system to treat MAFs. The use of the 3D grid plates has shown good clinical results. The efficiency of locking miniplate system is yet to be proven because there are few clinical studies with its use to fixate MAFs, although they have shown good results. When considering the use of semirigid or rigid fixation systems, the use of two miniplates outweigh the advantages of the use of one reconstruction plate, although the use of miniplates is not recommended for displaced comminuted MAFs. Although it has been shown that absolute rigid fixation is not necessary for fracture healing, any system that provides superior stability without impacting negatively on other aspects of the procedure, i.e., time, exposure, and cost, should be favored. MAFs can be treated in a highly effective way and with a relatively low rate of complications with monocortical miniplate fixation. The large number of studies on the treatment of MAF reflects the fact that a consensus has not been reached for a single, ideal treatment method.

Management of the fractured edentulous atrophic mandible

BACKGROUND

Fractures of the atrophic and edentulous (toothless) mandible (lower jaw) are fairly common in elderly people. Atrophy and weakening tend to occur as a result of reduced vascularity and decreased blood flow. Treatment options for reduction and fixation include closed and open techniques, with the degree of atrophy having a significant influence on the type of treatment. Many methods have been proposed for treating fractures of the atrophic mandible but there is still some uncertainty as to which method has the most successful outcomes.

OBJECTIVES

The objective of this review was to provide reliable evidence regarding the effectiveness of any interventions either open or closed that can be used in the management of fractured edentulous atrophic mandibles.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 4); MEDLINE from 1966 and EMBASE from 1980, both to 30th January 2006. Last search was done in January 2006.

SELECTION CRITERIA

Randomised controlled trials involving people over 55 years of age with fractures in the symphysis, parasymphysis, body, angle, ramus, condyle, and coronoid process of atrophic edentulous mandibles in which the fracture was a result of trauma, implant insertion or due to pathological fracture. Any studies that compared methods of management (open or closed reduction or fixation) were to be included.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies was conducted in duplicate and independently by two review authors. 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 including both clinical and methodological factors.

MAIN RESULTS

No eligible randomised controlled trials were identified.

AUTHORS' CONCLUSIONS

This review illustrates that there is currently inadequate evidence for the effectiveness of a single approach, either open or closed, in the management of fractured atrophic edentulous mandibles and that until high level evidence is available treatment decisions should continue to be based on clinician's prior experience. This absence of evidence may in part reflect a certain lack of clarity and the apparent diversity and lack of reliability in some of the traditional and normative predictors of successful outcomes.

A Short Period of Maxillomandibular Fixation for Treatment of Fractures of the Mandibular Tooth-Bearing Area

PURPOSE

This study was aimed to determine whether a short period of maxillomandibular fixation (MMF) followed by an arch bar splint wired to the lower jaw is a suitable alternative to conventional MMF for treatment of fractures of the mandibular tooth-bearing area.

PATIENTS AND METHODS

Thirty patients with mandibular fractures associated with no other facial fractures were selected. They were randomly assigned into 2 groups for treatment with conventional MMF (group A) and MMF for a short period of 2 weeks followed by an arch bar splint wired to the lower jaw (group B). Complications were recorded and post-treatment maximum interincisal mouth opening was measured at 1 week and 3 and 6 months. Age and gender-matched control groups were randomly selected. Groups were then compared for significant differences. A value of P < .05 was considered significant.

RESULTS

The 2 patient groups were not significantly different in relation to site and cause of fracture (P =.995 and P = .682, respectively), the mean time from injury to MMF (P = .234), and the mean time required for fracture healing (P = .315). Delayed union and nonunion were not encountered, and there were no significant differences in relation to postoperative infection ( P = 1) and malocclusion (P = .598). When compared with group A patients, group B patients had an early significantly greater degree in mouth opening (P = .001); at no time was there a significant difference in the degree of mouth opening between group B patients and the control group (1 week, P = .079; 3 months, P = .166; 6 months, P = .378).

CONCLUSION

In selected cases, a short period of MMF followed by an arch bar splint wired to the lower jaw is a suitable alternative to conventional MMF for treatment of fractures of the mandibular tooth-bearing area. The method is effective and significantly reduces the potential adverse effects of long-term MMF.

The pattern of maxillofacial fractures in Sharjah, United Arab Emirates: a review of 230 cases

OBJECTIVE

Maxillofacial injuries constitute a substantial proportion of cases of trauma. This descriptive analytical study assesses the cause, type, incidence, demographic, and treatment data of maxillofacial fractures managed at Al Qassimi Hospital in Sharjah, United Arab Emirates, during a 4-year period and compares them with the existing body of literature on the subject.

STUDY DESIGN

The medical records and radiographs of 230 patients treated for maxillofacial fractures at the Al Qassimi General Hospital over a 4-year period (from 1999 to 2002) were reviewed. A number of parameters, including the patient's age, gender, race, occupation, and mechanism of injury, type of facial injuries, treatment modality, and postoperative complications were recorded and assessed.

RESULTS

Men 20 to 29 years of age sustained the most maxillofacial fractures. The ratio of males to females was 11:1. Most fractures were caused by motor vehicle crashes (75%), followed by falls (12%) and violent assaults (8%). There were 150 (51%) mandibular, 102 (34%) maxillary, and 22 (7.4%) zygomatic fractures. Regarding distribution of mandibular fractures, the majority (25%, 38/150) occurred in the condyle, 23% (35/150) in the angle, and 20% (30/150) in the body. The distribution of maxillary fractures were 49.0% (50/102) dentoalveolar, 29.4% (30/102) Le Fort I, and 10.7% (11/102) were Le Fort II fractures. More than half of all cases were treated by closed reduction (67%). Complications occurred in 5.6% of patients.

CONCLUSION

The findings of this study, compared with similar studies reported in the literature, support the view that the causes and incidence of maxillofacial injuries vary from one country to another and, as such, can provide a guide to the design of programs geared toward prevention and treatment.

Strength analysis of intraosseous wire fixation for avulsion fractures of the fifth metatarsal base

The objective of this study was to gather pilot data of the pullout strength of intraosseous wire for fixation of fifth metatarsal avulsion fractures and to compare intraosseous wire fixation with tension-band wiring. Osteotomies consistent with fifth metatarsal avulsion fractures were created in 5 matched pairs of cadaver limbs. One limb of each pair underwent fixation with intraosseous wiring and the other with tension band wiring. Metatarsals were then loaded to failure, defined as the maximum force achieved before the slope of the load curve moved from a positive to a negative value. Tension-band wiring showed a mean strength of 164.5 +/- 103.7 N compared with a mean strength of 113.7 +/- 46.6 N for intraosseous wiring. No significant difference in strength was shown between methods of fixation. Although the power of this data is small (.143), the data indicate that intraosseous wiring shows similar pullout strength when compared with tension-band wiring for fixation of fifth metatarsal avulsion fractures.

Perioperative neurosensory changes associated with treatment of mandibular fractures

PURPOSE

The purpose of this study was to document perioperative neurosensory changes in the inferior alveolar nerve (IAN) after mandibular fracture treatment and to identify risk factors associated with these changes.

MATERIALS AND METHODS

This was a prospective cohort study composed of patients treated for mandibular fractures. The primary study variable was the change between the postinjury/pretreatment IAN neurosensory examination score and the score after fracture reduction. Risk factors were categorized as demographic, anatomic, and treatment. Appropriate descriptive, bivariate, and multivariate statistics were computed.

RESULTS

The cohort was composed of 61 patients with 97 fractured sides. Forty-seven fractures (49%) were located between the lingula and mental foramen, and 50 fractures (51%) were located distal to the mental foramen. Thirty-nine fractures (41%) were displaced by 5 mm or more. Abnormal preoperative IAN neurosensory examinations were documented in 81% of the fractured sides. Fifty-three fractures (54%) were treated by closed reduction and 44 (46%) by open reduction and internal fixation. In 82 fractures (85%), the IAN neurosensory score was unchanged or improved after treatment. In a multivariate model, preoperative neurosensory score, displacement, and treatment were associated with a statistically significant risk (P < or =.05) for postoperative deterioration of IAN sensation.

CONCLUSION

Open reduction and internal fixation, fracture displacement of 5 mm or more, and a normal preoperative IAN neurosensory examination were associated with an increased risk for deterioration of the IAN neurosensory score after treatment of mandibular fractures. Additional studies are indicated to determine long-term IAN neurosensory function after mandibular fracture treatment and the factors that affect prognosis.

Mandibular Angle Fractures

BACKGROUND

Noncompression monocortical miniplate fixation of the mandibular angle is an accepted and reliable method for providing rigid internal fixation. High complication rates have been reported for internal fixation of angle fractures.

OBJECTIVE

To analyze the outcome and complications in cases in which patients were treated with 2-miniplate fixation at the mandibular angle.

DESIGN

A retrospective analysis of outcomes for a case series.

SETTING

Treatment performed at a level 1 trauma-rated teaching hospital.

METHODS

From May 1992 to September 2001, a total of 88 patients with angle fractures of the mandible were treated with 2-miniplate fixation. Sixty-eight of the 88 patients, with 70 angle fractures, were included in the study; 13 were unavailable for follow-up and 7 had less than the minimum follow-up of 6 weeks. The time of trauma to treatment, cause of injury, and associated fractures were recorded. Postoperative complications, including infection, malunion, nonunion, dehiscence, osteomyelitis, and nerve injury due to surgical manipulation, were tabulated. Follow-up examinations were performed up to 12 weeks after surgery, with additional examinations if necessary. Postreduction panoramic radiographs were obtained in most cases.

RESULTS

No patients treated with monocortical 2-miniplate fixation had malunion, nonunion, or osteomyelitis. Twelve (17.6%) of the 68 patients were identified as having at least 1 postoperative complication. Postoperative infection occurred in 2 patients (2.9%). Infection was controlled with oral antibiotic therapy. One patient required removal of miniplates after the acute phase resolved. Occlusal disturbances were noted in 4 patients (5.9%) (2 with a slight anterior open bite, 1 with a crossbite, and 1 with premature contact of a molar) after surgery. Three of the 4 patients had associated midfacial or multiple mandibular fractures. None required further surgery. Wound dehiscence, with exposure of an underlying plate, occurred in 4 patients (5.9%); the wounds were treated conservatively and subsequently resolved. Nerve injury due to surgical manipulation occurred in 3 patients (4.4%).

CONCLUSIONS

Monocortical 2-miniplate fixation of the mandibular angle is a reliable and effective technique for providing rigid fixation. The complications were minimal in our study, and the infection rate was 2.9%, which is comparable to or better than the infection rate reported with the use of a single miniplate fixation technique in other studies. Disturbances of occlusion were associated with midfacial or additional mandibular fractures. In view of the contradictory published results, further studies are needed to determine the ideal approach for noncompression monocortical plate fixation of angle fractures.

Submental method for orotracheal intubation in treating facial trauma

OBJECTIVE

To demonstrate an alternative method for intubating patients with fractures of maxilla and nose, prior to surgery.

DESIGN

Cases Report.

PARTICIPANTS

We studied 10 patients with facial fractures that affected maxilla and nose.

INTERVENTION

The patients were submitted to surgery under general anesthesia and submental oro-tracheal intubation.

RESULTS

This type of intubation allowed the surgical team to work on the whole face of the patient and left no visible scar.

CONCLUSION

This procedure is indicated for patients with fractures of maxilla and nose who need surgical intervention under general anesthesia.

Complications and toxicities of implantable biomaterials used in facial reconstructive and aesthetic surgery: a comprehensive review of the literature

The use of implantable biomaterials has become an integral part of aesthetic and reconstructive surgery of the face. Metals are used for fracture fixation devices, whereas polymers are used primarily for bone or soft-tissue substitution. This review of the scientific literature examines the risks and complications of these materials. First, we present an overview of commonly used materials. Second, we address general considerations of toxicity relevant to all biomaterials. Third, we present data from a large number of clinical series on the incidence of complications for individual materials used in specific applications.

One- or two-plate fixation of mandibular angle fractures?

Standard treatment of mandibular angle fractures with miniplates, according to the recommendations of Champy et al. (1976), consists of fixation with one plate at the superior border of the mandible ventral to the external oblique line. In certain constellations, a second miniplate at the lower mandibular margin may provide additional stability. In contrast, extremely high complication rates following two-plate fixation of mandibular angle fractures were reported by Ellis and Walker (1994). In a prospective randomized study, 31 consecutive patients were treated with 2.0 mm (mini) plates (Synthes Co., Switzerland). One group was treated with one plate, the other one with two plates. In none of the patients was intermaxillary immobilization used. Follow-up was performed 6 months postoperatively, consisting of clinical and radiographic examination. No significant differences (P = 0.74 for infection, and P = 1.0 for occlusal and postoperative sensory disturbance) in postoperative short- or long-term complications were found between the two groups. The results are compared with our experimental investigations presented at the annual congress of the Germany Society of Oral and Maxillofacial Surgery, 1995. Two-plate fixation may not offer advantages over single-plate fixation in general. However, individual fracture constellations may benefit from variation in plate(s) localization. Factors contributing to complications in mandibular angle fractures are discussed.

Relative displacement resistance of standard and low-profile bone plates in experimental mandibular angle fractures

OBJECTIVE

The purpose of the study was to compare the resistance to displacement of low-profile and standard titanium bone plate with an experimental mandibular angle fracture model.

STUDY DESIGN

A jig was used to produce standard horizontally and vertically unfavorable mandibular angle fractures in 24 healthy baboon hemimandibles. Each hemimandible was immobilized with either a standard or a low-profile titanium bone plate with a Champy unicortical technique. The resistance to displacement was measured in a tensile-testing machine, and results were analyzed with a three-way analysis of variance.

RESULTS

Mean (SD) forces required to displace the fractures were standard plate 68.7 (22.8) kg and low-profile plate 46.5 (24.6) kg.

CONCLUSIONS

The standard plates provided significantly more resistance to displacement, and 75% of the low-profile plates fractured through a screwhole.

A comparative review of 266 mandibular fractures with internal fixation using rigid (AO/ASIF) plates or mini-plates

This study compares the internal fixation of mandibular fractures using either rigid 2.7 mm AO/ASIF plates or mini-plates. In the rigid plate group, 88 fractures were fixed with 88 plates. In the mini-plate group, 116 fractures were fixed with 170 plates. All the cases were consecutive and were treated in two South Wales hospitals during a 3-year period from 1988 to 1991. The aetiology of injury, timing of surgery, site of fracture, antibiotic policy and demographic features were evenly distributed between the two groups but there was a higher incidence of females in the mini-plate group. Both plating systems were successful in restoring functional occlusion. Rigid plates avoided the use of postoperative elastics better than mini-plates but the difference was not significant. There was a significantly higher incidence (P = 0.013) of infection in the mini-plate (12.9%) compared with the rigid plate (2.3%) group but 7.9% of the rigid group developed facial nerve weakness. A significantly higher proportion of mini-plates needed to be removed (P = 0.00019). A better treatment outcome for angle and comminuted fractures was noted with rigid plates.

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.

Mandibular fracture osteosynthesis: a comparison of three techniques

The authors report on a retrospective study of 205 consecutive patients at the Maxillofacial Unit of The Royal Melbourne Hospital to assess if adherence to Champy's principles in placement of miniplates in mandibular fractures minimises morbidity. 205 well documented cases of mandibular fractures treated with internal fixation, January 1985 to April 1990 were studied. The patients were assigned into three groups according to the type of fixation; 83 patients had miniplate fixation according to Champy's principles, 40 patients had miniplate fixation ignoring Champy's principles, 82 patients had transosseous wire (TOW) fixation. Outcome was measured by preoperative variables (age, gender, mechanism of fracture, site and number of fractures, nerve function, associated injuries and treatment delay) and postoperative variables (duration of admission, duration of intermaxillary fixation (IMF), malocclusion, infection, dehiscence, union, removal of fixation and nerve function which were assessed and compared. The results show that the preoperative variables were statistically similar in all groups. The postoperative variables indicated a statistically higher complication rate for the transosseous wire group compared with the miniplate groups, and morbidity was reduced in the group following Champy's principles. The morbidity rates in this study compare favourably with other studies even though the patients in this study had a much higher incidence of multiple fractures. Titanium miniplates appear as effective as miniplates constructed of other materials used in previous studies, especially when Champy's principles are followed.

Clinical and in vitro evaluation of mandibular angle fracture fixation with the two-miniplate system

More stable fixation and greater resistance against infection are achieved in mandibular angle fractures if the two-miniplate-fixation technique is used. One plate is applied at the superior border and a second plate is applied at the inferior border of the buccal cortex. Strong support for this argument was demonstrated in these in vitro and pilot clinical studies. It is concluded that the two-miniplate-fixation technique is indicated in cases of mandibular angle fracture to achieve stability of the fracture site and early mobility of the jaw.

Complications of treatment of mandibular fractures with compression plates

A total of 320 mandibular fractures with maxillomandibular fixation under local anesthesia were treated in this study. From this group, 244 fractures were treated with compression osteosynthesis. The complication rate was 13%; several patients had more than one complication. The complication rate decreased with the increase of operator experience. Malunions were recorded in 3.6% of the cases (1% in single and 7.5% in multiple fractures). Comminution, delay in treatment, and gross displacement were some of the factors related to malunion. The infection rate varied from 1% for those treated within the first week to 4% for those treated after at-least 2 weeks after the accident. Except for the delay in treatment, poor local conditions were a predisposing factor for infection. No infection was recorded in cases treated intraorally.

A retrospective analysis of 279 patients with isolated mandibular fractures treated with titanium miniplates

PURPOSE

This article addresses the suitability of semirigid fixation for the treatment of mandibular fractures.

MATERIALS AND METHODS

Between 1986 and 1991, 279 patients with 447 isolated mandibular fractures were treated with miniplate fixation using the tension-band principle of Champy et al. The time from trauma to treatment, etiology, number and location of the fractures, and the presence of preoperative infection and neurosensory disturbances were recorded. Postoperative complications such as infections, neurosensory disturbances, malocclusion, and nonunions also were recorded, as well as the reasons for removal of the miniplates.

RESULTS

Postoperative infection occurred in 10 patients (3.6%). These infections were controlled by antibiotics and the miniplates were removed after the acute phase. Occlusion disturbances were noted postoperatively in 13 patients (4.7%), and they were corrected by minimal occlusal grinding in the majority of cases. Neurosensory disturbances were noted preoperatively in 26.9% of the patients and 12 months postoperatively in 1.4% of the patients. Forty-seven plates (8.1%) in 32 patients (11.5%) were removed for a variety of reasons. No cases of nonunion occurred.

CONCLUSION

Semirigid fixation of mandibular fractures with miniplates is a viable treatment option for the management of such injuries.

The effect of osteotomy and osteosynthesis in the mandibular condyle. A radiologic and histologic study in sheep

Eighteen oblique osteotomies in sheep mandibular condylar necks were fixed with self-reinforced poly-L-lactide (SR-PLLA) (n = 9) or stainless steel (n = 9) screws (core diameters 2.4, 2.7, 3.0, or 3.5 mm). No intermaxillary fixation (IMF) was applied. The follow-up periods were 6, 12, and 24 weeks, respectively, after which the sheep were killed, and the status of the condylar head was assessed radiographically and histologically. The results showed that the fixation had been adequate. Bony destruction, osteophytes, and flattening of the condylar head, however, were frequently observed in both groups, as compared with the unoperated contralateral condyle. Histologic studies revealed that the thickness of the condylar head cartilage had increased and that the boundaries of the different cell layers were irregular, as was the junction of cartilage and bone. The diameter of the screw did not seem to have any influence on the occurrence of either radiologic or histologic signs of condylar degeneration. These findings indicate that screw fixation of condylar fractures in the mandible without IMF might result in degenerative joint disease.

Rigid fixation of mandibular fractures: does operator experience reduce complications?

Rigid internal fixation (RIF) is a frequently used method of reduction and immobilization of mandibular fractures. It has been postulated that the unexpectedly high complication rates reported in early studies of RIF were related to operator inexperience. The objective of this study was to determine if increased operator experience with RIF would result in a lower complication rate. Two 24-month patient care periods, separated by an intervening 12 months to avoid overlap, were evaluated retrospectively. Group 1 (n = 69 patients) represented the early experience and group 2 (n = 76 patients) the more recent data. The results of the study demonstrate a downward trend in the complication rate as surgeon experience increased. This improvement, however, was not statistically significant, and other factors may play a more important role in reducing complications.

Comparative evaluation of fixation methods after mandibulotomy for oropharyngeal tumors

Mandibulotomy for gaining access to the posterior aspect of the oral cavity and oropharynx for excision of tumors has been widely employed for several decades. However, the technical aspects of the procedure continue to evolve. This study compares the complications and bony union rates in a consecutive series of 135 patients undergoing mandibulotomy at 1 institution between 1987 and 1991, using wires and miniplates. The primary tumor sites were oral cavity in 35 patients, oropharynx in 98, and deep lobe of the parotid gland in 2. Twenty-eight patients were previously irradiated, and 62 received postoperative radiotherapy. Thirty-eight patients had a straight-line osteotomy, 31 had step osteotomy, and 66 had notched osteotomy. The fixation of the osteotomy site was done with wires in 59 patients and miniplates and screws in 76 patients. The duration of follow-up ranged from 1 to 5 years. No difference in complications or bony union was observed in patients who underwent repair with wires or miniplates. Due to the number of surgeons and their preferences for different types of osteotomies, as well as the differences in surgical techniques, we further studied the 2 methods of fixation employed by 1 surgeon who performed notched osteotomies on all of his patients (56 patients). Twenty-two underwent repair with wires, and 34 with miniplates. Four patients with wires and seven with miniplates developed wound complications requiring removal of wires in two and miniplates in one. Delayed union or nonunion was not observed in any patient. Fixation with wires or miniplates is equally satisfactory as long as adequate immobilization of the mandibular segments is achieved.

Evaluation of mandibular fracture treatment

A total of 124 patients treated for mandibular fractures were analyzed. Patients were divided into three groups according to treatment: intermaxillary fixation, wire fixation and mini-plate fixation. For each method, the success of treatment was evaluated with respect to surgical approach, fracture site and injury to treatment interval. Five basic parameters were used for evaluation of the outcome: occlusion, appearance, mastication, duration of IMF and complications. The treatment was surveyed based on both the surgeon's and patient's-evaluation. All parameters were scored and average values for every parameter calculated. The most successful treatment was achieved with mini-plate fixation in symphyseal and angle fractures. Intermaxillary fixation is indicated for mandibular body fractures with or without minimal displacement and a sufficient number of teeth. However, mini-plate fixation should be used for fractures with displacement. Wire fixation has been shown to be the poorest choice for all sites. Results showed that the intraoral approach has advantages over the extraoral one. The optimal time for treatment of mandibular fractures is within 72 h from time of injury. Even in fractures older than 7 days we recommended mini-plate fixation.

Mandible fractures--medical and economic considerations

This article retrospectively evaluates 1278 mandibular fractures and compares intermaxillary fixation, plating, and interosseous wiring as to outcomes and cost-effectiveness of treatment. The predominance of young men with personal altercations reflects the urban patient setting. The infection from plating exceeds other methods and this difference is also reflected in increased patient days (in the hospital) and an increased length of time for postoperative care. No significant differences are observed between treatments for non-union, malunion, facial nerve injury, or temporal mandibular joint problems. Other factors, such as site and severity of injury and experience of the surgeons are considered. Cost implications are important, but should be just one factor in evaluation for the best treatment for each patient.

Complications associated with rigid internal fixation of facial bone fractures

Rigid internal fixation is now a common method for treating fractures of the facial skeleton. However, it is a very precise technique that requires more time than intraosseous wiring. This article reports the complications associated with rigid internal fixation of facial fractures in 223 patients and compares the findings with those accompanying intraosseous wiring.

Maxillofacial trauma: influence of HIV infection

Between 1986 and 1990, 171 patients with mandibular and 129 with mid-face fractures were treated in our service. Both groups were separated into patients with HIV infection and patients without HIV infection. We carried out a retrospective review of these cases. The incidence of HIV+ve patients was higher in the mandibular fracture group (19.8%) than the group with mid-face fractures (7.75%). The most important aetiology of fractures was violence and the HIV infection was acquired through intravenous drug use (heroin). HIV infection was an independent associated factor where there was concomitant infection of mandibular fractures but not in mid-face fractures. In mandibular fractures, preoperative infections were significantly higher in HIV+ve patients (26.4%) than HIV-ve patients (6.5%) (p < 0.0001). Postoperative infections were higher in HIV+ve cases than HIV-ve cases, but this difference was not statistically significant (p > 0.05). Miniplates were a good osteosynthesis medium in HIV+ve patients and intermaxillary fixation seems to increase the infection rate in the HIV+ve group. The infections were treated with antibiotics with excellent results in preoperative infections and in the majority of postoperative cases, in both HIV+ve and HIV-ve patients.

Treatment of mandibular angle fractures using two mini dynamic compression plates

Thirty patients with 31 fractures of the mandibular angle were treated by open reduction and internal fixation using two mini dynamic compression plates with self-threading screws placed through a transoral incision with transbuccal trochar instrumentation. None of the patients were placed into postsurgical maxillomandibular fixation (MMF) or training elastics. Complications requiring secondary surgical intervention occurred in nine fractures (29%). Three were early infections requiring incision and drainage, removal of the hardware, and postoperative MMF. One was a nonunion with malocclusion requiring application of a more rigid bone plate. Five fractures developed late chronic swelling and low-grade infection requiring plate removal. Osseous union had occurred in these cases and no MMF was necessary. The use of two mini dynamic compression plates in the manner done in this study was found to be a relatively easy but unpredictable treatment for fractures of the mandibular angle.

The morbidity associated with fifty maxillary fractures treated by closed reduction

Fifty patients with maxillary fractures treated by closed reduction over an 85 month period at a Level I trauma center were reviewed. Thirty patients (60%) experienced forty-one midfacial complications. The most frequent problems were infraorbital nerve paresthesia (12), enophthalmus (5), septal deviation (3), and altered vision (3). No relationship could be established between complications and age, sex, cause of injury, or the method of suspension used. Most complications were related to concomitant injury or the concurrent management of fractures of other facial bones. Only eight problems (16%) were directly attributed to the closed reduction of maxillary fractures. Patients treated by closed reduction and maxillomandibular fixation without suspension experienced no surgical complications.

Infection after rigid internal fixation of mandibular fractures: a clinical and radiologic study

Of 214 patients with mandibular fractures treated following the AO/ASIF principle of rigid fixation, 13 patients (6.1%) developed postoperative infection. The yearly percentage decreased remarkably during the study period. When rigid fixation became a routine method, the infection rate was as low as the corresponding figure for cases treated with nonstable techniques and maxillomandibular fixation (MMF). All but one of the infected fractures were in the angular region of the mandible. Teeth had been extracted from the fracture line in 9 of the 10 dentulous patients. It was concluded that erroneous techniques had been used in almost all infected cases, because compression could not be achieved when there was an irregular fracture line, an atrophic edentulous mandible, or inadequate stability due to removal of a tooth in the line of fracture. In five patients, successful reoperation was performed using a reconstruction plate. Detailed radiologic examination was useful in assessment of infection and in follow-up.

Fixation of mandibular fractures: a comparative analysis of rigid internal fixation and standard fixation techniques

This study used a prospective design to compare standard therapy (closed or open reduction with 4 weeks of maxillomandibular fixation) to rigid internal fixation (RIF) for the treatment of mandibular fractures. Ninety-two patients with 143 fractures were evaluated and treated. There was no statistically significant difference in the treatment results between the two groups, despite a bias in the distribution of study variables that favored the standard therapy.

Transoral plating of mandibular angle fractures: a technique

A technique has been presented for transcutaneous management of angle fractures with employment of two plates: one at the tension band, the second at the compression zone of the mandible. Our preliminary experience with this procedure has been favorable. When a comparison is made of an intraoral approach to an extraoral one, there are three advantages. First, the cutaneous scar is minimal when compared with a transcutaneous one. Second, visualization of the occlusion is maintained throughout the procedure. Third, injury to branches of the facial nerve and other anatomic structures is reduced.

Use of mini-fragment bone plates for reduction of midface fractures

A technique for using small plates in the management of midface fractures is presented. Principles of fracture management are similar to wire osteosynthesis. Anatomic rigid reduction allows more precise control and stabilization of the midfacial bone fragments, particularly the frontal process of the maxilla and the medial canthal region. In addition, rigid fixation aids in preventing inferomedial displacement of the zygomatic complex by the masseter muscle. The vertical dimension of the midface can be reestablished and stabilized by bone plate fixation without the need for suspension wires. Immediate opening of the mouth afforded by rigid fixation facilitates safe airway management, patient comfort, better oral hygiene, and speech and may circumvent the need for tracheostomy when concomitant nasal fractures are present.

Rigid fixation: a review of concepts and treatment of fractures

Rigid fixation has been given considerable attention in the current literature. The concepts of treatment and the philosophies of the different systems vary, as do the results reported by different authors. This article reviews the basic tenets of rigid fixation and points out where systems are similar or diverge. Advantages and disadvantages of each system are covered.

The role of bacterial-laden biofilms in infections of maxillofacial biomaterials

Biomaterials from 11 consecutive patients with persistent infections refractory to antimicrobial therapy and local wound care were surgically removed and studied by scanning electron microscopy for the presence of bacterial-laden biofilms. Unlike previously reported biomaterial infections involving other regions of the body, infections in this study were not associated with a conspicuous bacterial-laden biofilm. Instead, adherent light bacterial colonization without a biofilm layer was noted. The only specimen that was suggestive of a bacterial-laden biofilm was in a patient who suffered from a chronic infection. Consistent with previous reports, bacterial colonization was frequently polymicrobial. Observations made in this study suggest that bacterial adherence may not require an obvious biofilm layer.