Management of Atrophic Mandible Fractures

Dental Implants Acting as External Fixation for the Fracture of Severe Atrophic Mandible: A Case Report

Treatment of edentulous and atrophic mandibular fractures is extremely difficult. Generally, mandibular fractures are repaired and fixed as internal fixation using a reconstruction plate or miniplates with intra- or extraoral approach. Few cases in which external fixation including a transmucosal fixation was performed have also been reported. We report a case of atrophic and edentulous mandibular fracture which was healed by the fixation using dental implants and implant-supported bridge.

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.

Novel approach for intermaxillary fixation of fractured mandible using gunning splints for easy disengagement: A case report

Intermaxillary fixation of gunning splints with an archwire necessitates precision in removal, which can prove hazardous during a life-threatening emergency. This case report describes the treatment of parasymphseal fracture of a patient hailing from remote location with inaccessibility to health care system. Intermaxillary fixation was performed with gunning splints using heavy orthodontic elastics, facilitating ease of removal in case of an emergency.

Risk Factors for Postoperative Inflammatory Complications After Maxillofacial Reconstruction Using Polyether-Ether-Ketone Implants

PURPOSE

Polyether-ether-ketone (PEEK) implants are increasingly used for the reconstruction of craniomaxillofacial deformities, but limited data exist on their limitations or risk factors for complications associated with their use. The purpose of the present study was to identify risk factors for postoperative inflammatory complications (POICs) after the use of PEEK implants in craniomaxillofacial reconstruction.

METHODS

A retrospective cohort study was conducted, incorporating all patients treated with patient-specific PEEK implants at the authors' institution from August 1, 2012 to June 30, 2019. The outcome variable was the presence of POICs. The potential predictor variables were demographic, medical, anatomic, and treatment related. Statistical analysis was performed using Fisher exact tests, t tests, and multivariable logistic regression analysis where appropriate.

RESULTS

The 32 patients included in the study were composed of 68.8% men; mean age was 40.6 years. The PEEK implant was placed adjacent to the paranasal sinuses in 56.3% of patients. The indication for use was malar depression in 50.0%, orbital dystopia in 46.9%, forehead or skull defects in 21.9%, and mandibular contour deformities in 6.2%; 8 patients had more than 1 indication. The overall rate of POICs was 28.1%. Of the POICs, 66.7% were managed with incision and drainage, revision surgery, or removal and 33.3% were managed with outpatient wound care or antibiotics. Tobacco use, the presence of an intraoral incision, and the presence of multiple incisions were all associated with POICs. On multivariable analysis, tobacco use approached significance (odds ratio, 17.3 [95% confidence interval, 0.98 to 306.7]) and multiple incisions (odds ratio, 6.9 [95% confidence interval, 1.5 to 32.3]) had a statistically significant association with the occurrence of complications.

CONCLUSIONS

The present study identified several variables potentially associated with complications after the use of PEEK implants in maxillofacial reconstruction. Consideration should be given in the preoperative evaluation when a smoker is identified and when multiple incisions are planned.

The Effects of Frontal Trauma on 4 Interforaminal Dental Implants: A 3-Dimensional Finite Element Analysis Comparing Splinted and Unsplinted Implant Configurations

PURPOSE

With increased implant-prosthodontic rehabilitation for mandibular edentulism together with the increased life expectancy and activity of the elderly population, a greater number of implant patients may be at risk of facial trauma. The aim of this 3-dimensional (3D) finite element analysis (FEA) was to evaluate the biomechanical effects of the edentulous mandible (EM) with and without implants exposed to frontal facial trauma including assessment of the fracture risk of different mandibular areas.

MATERIALS AND METHODS

By use of a 3D FEA, our experimental study design comprised 3 different models (model A, EM; model B, EM with 4 unsplinted interforaminal implants; and model C, EM with 4 splinted interforaminal implants) exposed to application of symphyseal frontal trauma of 2 MPa. In 3 defined regions of interest (ROIs) (ROI 1, symphyseal area; ROI 2, mental foraminal area; and ROI 3, condylar neck), the effective stress was measured at predefined sites in the superficial cortical mandibular area. The stress values of all ROIs evaluated were compared within each model (intramodel) as well as between the 3 models (intermodel).

RESULTS

For all models evaluated, a frontal traumatic load generated the highest stress levels in the condylar neck. However, for both models with implants (models B and C), the stress values were reduced significantly (P < .01) in the condylar neck region (ROI 3) but increased significantly (P < .001) in the mental foraminal area (ROI 2) compared with the EM model without implants. For the symphyseal area (ROI 1) evaluated, the unsplinted 4-implant model (model B) presented significantly (P < .001) higher stress values than the splinted implant model (model C) when frontal forces were applied.

CONCLUSIONS

Regardless of splinting or lack of splinting of 4 interforaminal implants, force absorption or transmission may shift the predominant risk factor from the condylar neck to the corpus or foramen mandibulae. However, splinting of 4 interforaminal implants may be beneficial in reducing the risk of bone fracture by providing protection for anterior risk situations.

Postoperative CT of the Mandible Following Trauma: Review of Normal Appearances and Common Complications

RATIONALE AND OBJECTIVES

Surgeons aim to restore occlusion and jaw function to baseline status for patients with mandibular fractures using either closed treatment or reduction and fixation.

MATERIALS AND METHODS

Occlusion is defined as the relationship between the maxillary and mandibular teeth as they approach each other.

RESULTS

Radiologists should be familiar with the goals of repair to help identify which treatment is adequate as well as to diagnose potential complications. Some of the more common complications encountered are infection, nonunion or malunion, and malocclusion.

CONCLUSION

We provide a comprehensive review of both the desired and untoward CT findings after surgical repair of traumatic mandibular injuries.

Use of the MatrixWAVE™ system with dentures to establish maxillomandibular fixation in edentulous patients

Various methods have been described to establish maxillomandibular fixation in the treatment of fractures of atrophic, edentulous mandibles. We used the Synthes MatrixWAVE™ system (DePuy Synthes) in combination with dentures in two patients with fractured, edentulous, atrophic mandibles. Fixation was maintained for fractures that were not amenable to, or did not require, open reduction and internal fixation, and the mandibles were both well-healed and had good function at the end of treatment.

Management of Bilateral Edentulous Mandible Fractures Through an Intraoral Approach Using CAD/CAM Technology: A Case Report

The surgical management of edentulous mandible fractures presents unique challenges secondary to poor bone stock and the absence of dentition to assist with fracture reduction. In complex injury patterns, such as bilateral edentulous mandible fractures, an external approach is often necessary to achieve adequate reduction and adaptation of a load-bearing reconstruction plate. We report a case in which computer-assisted design/computer-assisted manufacturing (CAD/CAM) was applied as an adjunct for the acute management of bilateral edentulous mandible fractures in a 58-year-old man. CAD/CAM technology was used to fabricate a patient-specific reconstruction plate and a maxillomandibular splint, which facilitated the successful treatment of this complex injury through an intraoral approach. This case highlights the potential of CAD/CAM technology to improve operative efficiency and clinical outcomes in the acute management of complex edentulous mandible fractures.

A Technique for Reduction of Edentulous Fractures Using Dentures and SMARTLock Hybrid Fixation System

Establishing anatomic reduction of an edentulous mandible fracture is a frequently acknowledged challenge in craniomaxillofacial trauma surgery. In this study, we report a novel method for the reduction of the edentulous mandible fracture, via fabrication of modified Gunning splints using existing dentures and SMARTLock hybrid arch bars. This technique dramatically simplifies the application of an arch bar to dentures, obviates the need for the fabrication of impressions and custom splints, and eliminates the lag time associated with the creation of splints. Furthermore, this method may be used with or without adjunctive rigid internal fixation. The technique described herein of creating Gunning splints with SMARTLock hybrid arch bars provides surgeons with a simple, rapid, single-stage solution for reduction of mandibular fractures in the edentulous patient.

Virtual Surgical Planning for the Management of Severe Atrophic Mandible Fractures

Severely atrophic mandible fractures are frequently a challenge to treat. Virtual surgical planning (VSP) uses three-dimensional computed tomographic (CT) scans that can be translated into stereolithographic models to fabricate surgical templates, facilitating intraoperative procedures. The purpose of this article is to describe the reconstruction of two cases of severe atrophic mandible fracture using VSP. Two elderly edentulous/partially dentate patients who presented with fractures of their mandibles and who underwent reconstruction using VSP were included. Both had Class III atrophy at the region of the fracture. While both fractures were complex, the mechanism of injury differed with one being a tractor accident and the other being a pathologic fracture. Both patients presented with critical medical conditions. CT scans were obtained on both. The displaced segments were aligned virtually using mirror images and the midline of the maxilla. Three-dimensional models were fabricated to allow preoperative contouring of 2.5-mm reconstruction plates. Patients were operated under general anesthesia and fractures reduced and stabilized with 2.5-mm reconstruction plates placed at the lateral border of the mandible. Average treatment time for both patients was a little over 2 hours. There was good reduction with both. VSP is a valuable tool to assess and reduce complex fractures with less surgical time and predictable results.

Analysis of the blood supply to the post-fracture edentulous mandible: study by colour Doppler sonography

PURPOSE

This study assessed the arterial blood supply to the mandible of edentulous patients treated for mandibular fractures using colour Doppler ultrasound.

METHODS

The blood supply of edentulous patients surgically treated for mandibular fractures (group A) and edentulous fracture-free individuals (group B) was assessed. Only the fractured sides were evaluated in the first group (N = 17), whereas each side was evaluated in the second group (N = 20). The arterial flow of six sites was assessed. The systolic-peak maximum velocity (SPV), final diastolic velocity (FDV), resistive index (RI), pulsatility index (PI), acceleration and flow direction of each artery were obtained. Additionally, the presence of local vascular obstructive factors was evaluated. The differences between groups were analysed using the Kruskal-Wallis test, which was complemented by the Mann-Whitney test, for correlations between the degree of alveolar atrophy and the study factors (p < 0.050).

RESULTS

There was a significant decrease in the flow of certain arteries, especially the submental (SPV, p = 0.007, PI, p = 0.022, and acceleration, p = 0.015), in the fracture group. The facial artery in both groups showed lower values related to local obstructive factors (SPV, p = 0.001, FDV, p = 0.040, and PI, p = 0.030). The submental artery flow was higher (SPV, p = 0.006, and FDV, p = 0.009) in non-atrophic individuals.

CONCLUSIONS

There was a decreased flow mainly in the submental artery, but there were no cases of major vascular injury in edentulous patients treated for mandibular fractures.

Tissue Engineering for Vertical Ridge Reconstruction

This article provides an overview of basic tissue engineering principles as they are applied to vertical ridge defects and reconstructive techniques for these types of deficiencies. Presented are multiple clinical cases ranging from office-based dentoalveolar procedures to the more complex reconstruction of postresection mandibular defects. Several different types of regenerative tissue constructs are presented; either used alone or in combination with traditional reconstructive techniques and procedures, such as maxillary sinus augmentation, Le Fort I osteotomy, and microvascular free tissue transfer. The goal is to also familiarize the reconstructive surgeon to potential future strategies in vertical alveolar ridge augmentation.

Unsuccessful Treatment of Atrophic Mandible Fracture by Use of Improper Materials

Fractures of atrophic mandibles are present on the day by day of buccomaxillofacial surgeons. Mandible atrophy occurs due to tooth loss, which over time induces bone resorption leading to a fragile and susceptible to fracture structure. This paper reports the case of a patient victim of face trauma resulting in atrophic mandible fracture with treatment failure through the use of shared load miniplate. Therefore, a new treatment was performed with miniplate of system 2.4 along with bone graft. After 6 months, the patient was rehabilitated with implant-supported prosthesis installation. It is concluded that for successful treatment of atrophic mandible fractures, the use of rigid plates is necessary, allowing an excellent rehabilitation of the stomatognathic system.

Spontaneous fractures of the mandible concept & treatment strategy

Background

Spontaneous fractures of the mandible dispose a surgical challenge in comparisons to fractures caused by trauma due to several complicating factors. Additionally: controversies exist concerning the terminology of the field.

Material and Methods

We conducted a retrospective study of all patients with mandibular fractures, with exclusion of fractures of the coronoid process and the alveolar process, treated at the Department of Oral and Maxillofacial Surgery, Aalborg University Hospital, Denmark between February 2003 and February 2013. Data collected from the medical records included sex, age, cause of fracture, site of fracture, and treatment.

Results

We identified 517 patients with 684 mandible fractures. Twenty-five of these were spontaneous fractures and 659 fractures were of traumatic origin. Condylar fractures rarely occur spontaneously, but constitute the majority of the traumatic fractures. Excluding these fractures from the analysis, we found a non-surgical approach in 14 of 24 (58%) of the spontaneous fractures and 110 of 376 (29%) of the traumatic fractures. This was statistically significant.

Conclusions

We found a statistical significant difference in favor of non-surgical approach in spontaneous fractures and we discussed the treatment challenges of these fractures. We addressed the terminological controversies regarding pathological fractures, and suggested the term spontaneous fractures denoting a fracture occurring during normal jaw function being either pathological or non-pathological.

Key words:Mandibular fractures, spontaneous fractures, pathological fractures, traumatic fractures, treatment.

Stability of edentulous, atrophic mandibles after insertion of different dental implants. A biomechanical study

OBJECTIVES

Fractures of the atrophic edentulous mandible are a rare complication that can become severe after the insertion of dental implants. This in vitro study investigated the effects of different implant settings varying in number, diameter, and length. and the influence of a fixed bar.

MATERIALS AND METHODS

In biomechanical experiments on artificial mandibles, an unmodified reference group, four implant settings with two different implants, and the effect of adding a fixed bar to these settings were tested. All specimens were loaded with incisal biting forces until failure due to fracture.

RESULTS

Implants weakened all specimens significantly compared with those in the reference group. Without a fixed bar, four short and thick implants showed the best results, with high significance. With a fixed bar, four long and thin implants withstood the highest loads. The addition of fixed bars reduced the differences between the implant settings. Fixed bars did not show increased stability for all groups; however, these groups showed a higher mean strength.

CONCLUSIONS

Four implants with a short and thick design should be the first choice when implants are placed without a fixed bar in an atrophic mandible. With a fixed bar, four long and thin implants should be used.

An unusual case of atrophic mandible fracture in a patient with osteogenesis imperfecta and on oral bisphosphonate therapy: Case report

Fractures of severely atrophic (height < 10 mm) edentulous mandibles are infrequent and challenging to manage. Factors such as sclerotic bone and decreased vascularity combined with systemic diseases complicate the management of such fractures. Osteogenesis imperfecta (OI) is a heterogeneous group of inherited disorders of type I collagen metabolism. Patients with OI characteristically present with histories of long bone fractures, deformities, blue sclerae, and opalescent dentin. However, fractures of the facial skeleton are rare. Bisphosphonate therapy has been proven to effectively reduce the fracture risk in patients with OI. The purpose of this clinical report is to present an unusual case of spontaneous fracture of the atrophic mandible in a patient with OI. Despite open reduction and internal fixation (ORIF) with miniplate osteosynthesis, the patient developed a second fracture at a screw placement site distal to the first fracture. The patient was successfully treated with ORIF using locking reconstruction plates fixed in the symphyseal and angle regions. Bone healing following ORIF was normal, and no clinical sign of osteonecrosis as a result of bisphosphonate therapy was observed. Patients with OI can present with spontaneous fractures of already weakened mandibles. Although such fractures can be managed with care using established protocols, further research is required to examine the effects of concomitant medication, such as bisphosphonates.

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.

A novel technique for attaining maxillomandibular fixation in the edentulous mandible fracture

Edentulous mandible fractures present a unique and challenging surgical problem, particularly because of lack of occlusive dental surfaces to capitalize upon maxillomandibular fixation (MMF). We present a novel technique to achieve MMF using rigid plates spanning the oral cavity to fixate the maxilla to the mandible. The process is rapid and allows stability using the established principles of rigidity, external fixation, and osteosynthesis. This technique allows for a faster MMF than with a Gunning splint and allows for easier oral hygiene. An illustrative case and pre- and postoperative imaging are provided.

A mandibular body fracture related to mouth-opening training in a dialysis patient

A mandibular body fracture related to mouth-opening training in a dialysis patient is reported. A 61-year-old male patient had noticed pain in the right mandibular body and difficulty in mouth opening a week previously. The patient had been performing mouth-opening training for a couple of weeks. The right lower face was slightly swollen with tenderness at the right lower border of the mandible. Hypoesthesia of the right lower lip was also observed. A bone step was palpable on the alveolar ridge of the right mandible, but mobility was not marked. The mandible was atrophic in the body region with only four anterior teeth left. Panoramic X-ray examination revealed a moderately displaced fracture in the right molar region of the mandible. The patient had no severe pain or difficulty in eating using a partial denture. The patient had received dialysis for 17 years and had also been treated by warfarin and aspirin. The patient was followed up under restricted mouth opening. Osteosynthesis with bone remodeling was confirmed after 6 months by X-ray examination. No complication requiring further treatment occurred during the follow-up period. In this patient, a medically compromised condition under long-term dialysis is considered a predisposing factor, which made the atrophic mandible more susceptible to the stress related to mouth-opening training.

Fracture of the atrophic mandible: case series and critical review

PURPOSE

Atrophic mandible fracture is common among elderly patients. Such fractures present management difficulties related to anatomic and physiologic alterations in this population. The purpose of this study was to evaluate the results of this type of fracture treatment and to realize a critical review of literature on the subject.

PATIENTS AND METHODS

The sample was obtained from records of patients of Restauração Hospital (Recife, Brazil) who underwent surgical treatment of atrophic mandible fracture between 2006 and 2009. Data, such as etiology, location, and degree of displacement of the fractures, as well as access, type of fixation used, and the presence of postoperative complications, were analyzed.

RESULTS

Successful bone union was achieved in 100% of cases. Complications were related to those patients treated with reconstruction plates (2.4 mm).

CONCLUSIONS

Open reduction and internal fixation with miniplates seem a feasible option for primary treatment of atrophic mandible fractures without comminution or loss of substance. The level of scientific evidence for the treatment of atrophic mandible fractures is low.

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

The present study aimed at evaluating the treatment outcome of fractures of the edentulous atrophic mandible by means of an extraoral approach using open reduction and internal fixation with macroplates. Eighteen patients with 21 fractures of the atrophic mandible, who had been treated between 1997 and 2006, were retrospectively analysed. Mandible height was categorised according to the Luhr classification and the patients' general health (The American Society of Anesthesiologists (ASA) classification). Three types of titanium macroplates were used. Demographic data, treatment outcomes and the pre- and postoperative ability to wear mandible dentures were evaluated. The study population consisted of five men and 13 women with a median age of 78 years. The mean follow-up duration was 28 months. The most common cause of fractures was accidental falls (50%); the mandible was affected in 77.8%. Three fractures occurred in class I (bone height 15-20 mm), seven in class II (10-15 mm), and 11 in class III atrophy (<10 mm). According to the ASA classification, the collective showed a mean value of 3. An overall complication rate of 16.7% was noted, consisting of two minor and one major complication that required a second intervention. Five patients needed removal of the osteosynthesis material for prosthetic reasons. Only 50% of the patients were able to wear their dentures before surgery, and all but one were able to wear their prosthesis postoperatively. Treatment of atrophic mandible fractures with macroplates by means of an extraoral approach showed good results and a low complication rate. This procedure allows elderly patients to instantly load the mandible in the means of prosthetic and masticatory rehabilitation, preventing the necessity for second interventions.