Superior border versus inferior border fixation in displaced mandibular angle fractures: prospective randomized comparative study

Infection Rates of an Intraoral Versus Extraoral Approach to Mandibular Fracture Repairs are Equal: A Systematic Review and Meta-Analysis

PURPOSE

This study investigates whether the intraoral approach to mandibular open reduction and internal fixation, through exposure to the oral cavity's microbiome, results in higher infection rates compared to the extraoral approach, thus addressing a critical public health concern, potentially offering an opportunity to reduce health-care costs, and aiming to guide effective clinical practice.

METHODS

In this systematic review with meta-analyses, a review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A comprehensive literature search was conducted using Embase and PubMed for articles published between 1989 and 2023. Inclusion criteria targeted studies on open reduction and internal fixation mandibular fractures comparing intraoral and extraoral approaches and reporting infection rates. Exclusion criteria eliminated non-English articles, case reports, and studies with insufficient approach-specific data. The primary outcome was the postoperative infection rate, with surgical approach as the predictor. Covariates such as age, sex, diabetes, and smoking status were included when reported. Data were analyzed using R software, employing random-effects models due to anticipated heterogeneity (I2 statistics).

RESULTS

From 61 studies, 11 provided direct comparisons involving 1,317 patients-937 intraoral and 380 extraoral. Infection rates were 5.9% for intraoral and 10% for extraoral approaches. Pooled relative risk was 0.94 [95% confidence interval, 0.63, 1.39], suggesting no significant risk difference. Prevalence of infections was estimated at 9% for intraoral and 6.1% for extraoral procedures, with significant heterogeneity (I2 = 84% for intraoral and 56% for extraoral).

CONCLUSION

Our meta-analysis found no significant difference in infection rates between the two approaches. There is opportunity to expand on reporting complication rates comparing the various approaches to mandibular fixation. Until these data are presented, surgeon preference may dictate the operative approach to expose the mandible for reduction and fixation.

Complications after different methods for fixation of mandibular angle fractures: network meta-analysis of randomized controlled trials

The aim of this review was to compare mandibular angle fracture fixation methods that were evaluated through randomized clinical trials considering postoperative complications. Additionally, different treatment methods were ranked based on their performance. A systematic review was performed based on the Cochrane and PRISMA guidelines. The quality of evidence and network meta-analysis were conducted using the GRADE tool and R software, respectively. Four databases were searched, and the papers were selected based on the PICOS strategy. A total of 3584 papers were found. After screening 15 papers were included. One plate placed on lateral border (tension zone) presented lower risk than one plate placed on superior border (tension zone) for infection [risk ratio (RR): 0.48, 95% confidence interval (CI): 0.33 to 0.71] and plate removal necessity (RR: 0.44, 95% CI: 0.28 to 0.69), with moderate quality of evidence. There were no significant differences among the mandibular angle fracture treatments for malocclusion and paraesthesia outcomes. In conclusion, one plate placed on the lateral border in the tension zone is the best choice regarding postoperative infection and plate removal necessity when fixing mandibular angle fractures. None of the tested fixation methods were associated with a significant risk of malocclusion and paraesthesia events.

A comparison of panoramic radiography and cone beam computed tomography in the detection of osteosynthesis complications in sheep mandibular angle fractures

OBJECTIVE

The aim of this study was to compare the diagnostic efficacy of panoramic radiography (PANO) and cone beam computed tomography (CBCT) in detecting simulated complications of plate osteosynthesis applied to mandibular angle fractures (MAFs).

STUDY DESIGN

Unfavorable MAFs were created in 100 fresh sheep hemimandibles. Fractures were fixed with 4-hole titanium miniplates and screws. Bone necrosis around the screws, penetration of the screw into the inferior alveolar canal, screw loosening, and plate breakage were simulated. The diagnostic efficacy of the imaging techniques was compared by using intra- and interobserver agreement scores and area under the receiver operating characteristic curve (AUC) values. Examination time (ET), confidence scores (CS), and planar preference (PP) in CBCT evaluation were assessed.

RESULTS

Intra- and interobserver agreement scores varied between 0.61 and 0.91. AUCs for screw penetration into the inferior alveolar canal and screw loosening were significantly higher in CBCT than in PANO (P < .05). CBCT presented significantly higher ET and CS values compared with PANO (P < .05). PP showed significant differences among types of complications (P < .05).

CONCLUSIONS

PANO provided acceptable outcomes in the detection of bone necrosis and broken plates around the screw, but CBCT was more likely to enable detection of all simulated types of complications with higher confidence.

Comparison of single versus two non-compression miniplates in the management of unfavourable angle fracture of the mandible: a prospective randomized clinical study

PURPOSE

The purpose of this study was to compare the efficacy of single versus two non-compression miniplates in the management of unfavourable angle fracture of mandible.

MATERIALS AND METHODS

A total of 28 patients who required open reduction of mandibular angle fracture were included in the study. The patients were randomly divided into two groups. Group I comprised of patients treated with two miniplates and those in group II were treated with single non-compression miniplate. The parameters of assessment were malocclusion, surgical site infection, need for implant removal, duration of surgery, inter-incisal mouth opening and cost of implants used, in both the groups. Statistical analysis was carried out to compare all the parameters.

RESULTS

Out of 14 patients in group II, inadequate reduction was noticed in three patients, whereas screw loosening had occurred in two cases. Screw loosening was always associated with chronic infection. In these cases, hardware removal was deemed necessary. Plate bending was observed in two cases resulting in malocclusion and difficulty in eating. Non-union of fracture occurred in one patient treated in group II. In group I, no plate bending, screw loosening, surgical site infection, non-union or malocclusion was observed. No patient had to undergo implant removal in group I.

CONCLUSION

In the management of unfavourable mandibular angle fracture, two miniplates must be preferred over the use of single miniplate as using two miniplates results in better results with minimal complications.

Surgical Management of Unusual Biangular Mandibular Fractures

Bilateral mandibular angle fractures, while representing a rarity among mandibular fractures, are a huge challenge of complex management for the maxillofacial surgeon. There are still many open questions regarding the ideal management of such fractures, including the following: the removal of the third molar in the fracture line, the best surgical approach, and the fixation methods. In this report the authors present the case of 40-year-old man presenting with a bilateral mandibular angle fracture referred to the Maxillofacial Surgery Department of Turin. Open reduction and internal fixation has been made for both sides. The left side third molar was removed and the internal fixation was achieved through internal fixation with one miniplate according to Champy's technique and transbuccal access for a 4-hole miniplate at the inferior border of the mandible. Right side third molar was not removed and fixation was achieved through intraoral access and positioning of a 4-hole miniplate along the external ridge according to Champy. An optimal reduction was achieved and a correct occlusion has been restored.

Effect of interfragmentary gap on the mechanical behavior of mandibular angle fracture with three fixation designs: A finite element analysis

BACKGROUND

The aim of this study was to simulate stress and strain distribution numerically on a normal mandible under physiological occlusal loadings. The results were compared with those of mandibles that had an angle fracture stabilized with different fixation designs under the same loadings. The amount of displacement at two interfragmentary gaps was also studied.

MATERIALS AND METHODS

A three-dimensional (3D) virtual mandible was reconstructed with an angle fracture that had a fracture gap of either 0.1 or 1 mm. Three types of plate fixation designs were used: Type I, a miniplate was placed across the fracture line following the Champy technique; Type II, two miniplates were used; and Type III, a reconstruction plate was used on the inferior border of the mandible. Loads of 100 and 500 N were applied to the models. The maximum von Mises stress, strain, and displacement were computed using finite element analysis. The results from the control and experimental groups were analyzed and compared.

RESULTS

The results demonstrated that high stresses and strains were distributed to the condylar and angular areas regardless of the loading position. The ratio of the plate/bone average stress ranged from 215% (Type II design) to 848% (Type I design) irrespective of the interfragmentary gap size. With a 1-mm fracture gap, the ratio of the plate/bone stress ranged from 204% (Type II design) to 1130% (Type I design). All strains were well below critical bone strain thresholds. Displacement on the cross-sectional mapping at fracture interface indicated that uneven movement occurred in x, y, and z directions.

CONCLUSIONS

Interfragmentary gaps between 0.1 and 1 mm did not have a substantial effect on the average stress distribution to the fractured bony segments; however, they had a greater effect on the stress distribution to the plates and screws. Type II fixation was the best mechanical design under bite loads. Type I design was the least stable system and had the highest stress distribution and the largest displacement at the fracture site.

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.

Management of Mandibular Angle Fractures: Single Stainless Steel Linear Miniplate Versus Rectangular Grid Plate-A Prospective Randomised Study

PURPOSE

This prospective study was conducted to evaluate the efficacy of stainless steel single linear miniplate with rectangular grid plate in the treatment of mandibular angle fractures.

METHODS

This study included 30 patients who were allocated randomly into two groups of each. Group 1 patients were treated with single 2 mm × 4 hole linear stainless steel miniplate and group 2 patients with 2 mm × 4 hole rectangular grid plate. Patients were evaluated for fracture stability, occlusion, mouth opening, and complications at 1st week, 1 and 3 months post operatively.

RESULTS

There were no significant differences between the two groups with respective variables statistically. In group 1 20 % (n = 3) had mild occlussal derangement 6.66 % (n = 1) patient had deranged occlusion at 1 week post operatively and 13.3 % (n = 2) had mild derangement at 1 month post operatively. In group 2 6.66 % (n = 1) had mild derangement at 1 week postoperatively. 20 % (n = 3) had limited mouth opening at 1 week in group 1 and 13.3 % (n = 2) in group 2. All patients in both groups achieved adequate mouth opening by the end of 3 month. None of the patients in both groups had plate fracture, screw loosening, non union or mal-union.

CONCLUSION

Within the limits of the study, use of rectangular grid plates for fixation of mandibular angle fractures was reliable with low complication rates, easy adaptation and an effective alternative to conventional miniplates. Further clinical studies with larger sample size can derive a more comprehensive conclusion.