A comparison of three treatment methods for fractures of the mandibular angle

Does a Short Period of Maxillomandibular Fixation Decrease Complications in Open Reduction Internal Fixation of Mandibular Angle Fractures?

PURPOSE

A short duration of postoperative maxillomandibular fixation (MMF) has the potential to reduce complications following open reduction and internal fixation (ORIF) of mandibular angle fractures. The purpose of this study was to determine if a short duration of MMF is associated with a reduced rate of postoperative inflammatory complications (POICs) in patients with mandibular angle fractures undergoing ORIF.

METHODS

The authors conducted a retrospective cohort study consisting of patients treated with ORIF for mandibular angle fractures from August 1, 2015 to May 31, 2020 at an urban, level 1 trauma center. Patients under the age of 18 years, bilateral angle fractures, those with MMF periods of more than 3 weeks, and those patients without documentation of the duration of MMF were excluded from the study. The primary predictor variable was the use of a short duration (less than 2 weeks) of postoperative MMF. The outcome variable of interest was the presence of POICs. Categorical covariates were compared using Fisher's exact tests, while continuous variables were compared using Wilcox rank-sum tests. Multivariable logistic regression adjustment was also performed.

RESULTS

There were 307 patients included in the study, 84.4% of which were men. The average age was 32.5 years. Patients with a short duration of MMF had a POIC rate of 8.3% compared to 18.2% for no MMF (P = .08). In the adjusted analysis, patients with a short duration of MMF time had a significant decrease in POIC risk compared to no MMF (adjusted odds ratio [aOR] = 0.32, 95% confidence interval [CI] = 0.11 to 0.97). Other significant variables in the regression analysis included plating type and noncompliance. Inferior border rigid fixation was associated with decreased POIC risk compared to ladder plates and lateral border plates (aOR 5.8, 95% CI = 1.8 to 18.4 and aOR 5.1, 95% CI = 1.4 to 18.7, respectively).

CONCLUSION

The findings from our study suggest that a short duration of postoperative MMF may reduce POICs following ORIF of mandibular angle fractures.

Investigation of the biomechanical stability of Cfr-PEEK in the treatment of mandibular angulus fractures by finite element analysis

The purpose of this study is to explore the effectiveness of Cfr-PEEK, in the fixation of unfavorable fractures of mandibular angulus by comparing it with the titanium and resorbable biomaterials. 8 different fixation models were created. In the first 4 groups, a single mini plate was applied to the upper edge of the fracture line by the Champy method. In the other 4 groups, an additional plate was placed on the lower edge of the fracture line. In these models, titanium, resorbable and Cfr-PEEK plate/screw systems were investigated by the finite element analysis method. The highest Von Mises stress was observed on the upper plate in the group 5 while the lowest was seen in the lower plate in the group 7. The highest stress values on the screws were observed on the screws placed closer to the fracture line. Considering the stresses on the bone around the screws, the highest Pmax and Pmin values were seen in group 5, and the lowest values were seen in the group 7. The highest displacement was observed in the group 3, while the lowest was observed in the group 5. According to the results it can be said that Cfr-PEEK plate/screw systems may provide advantages by decreasing the stresses on the fixation systems over the titanium plates and providing more stable fixation over the resorbable systems. Cfr-PEEK plates of 2 mm thickness seems to be a potential alternative to 1 mm thick titanium plates.

One miniplate versus two miniplates in the fixation of mandibular angle fractures. An updated systematic review and meta-analysis

PURPOSE

The aim of this study is to compare the outcomes after using one miniplate fixation in the external oblique ridge versus two miniplate fixation for mandibular angle fractures.

METHODS

A systematic review of MEDLINE (via PubMed), Scopus and Cochrane Library database was performed (last search date: 04 February 2022) according to the PRISMA guidelines. The research question was addressed using the PICO criteria. Only comparative studies between the two techniques were included. Random-effects model meta-analyses were performed.

RESULTS

Seventeen studies, comprising a total of 1667 patients, 846 undergoing one miniplate fixation and 854 undergoing two miniplate fixation for mandibular angle fractures were identified. No statistically significant differences were observed regarding surgical site infection (odds ratio [OR]= 0.94, 95% confidence interval [CI]: [0.69] - [1.28], p = 0.68, I²=0.00%), post-operative malocclusion (OR= 0.97, 95% CI: [0.53] - [1.18], p = 0.25, I²=0.00%), post-operative neurosensory dysfunction (OR= 0.67, 95% CI: [0.37] - [1.22], p = 0.19, I²=73.93%), pseudoarthrosis formation (OR=0.90, 95% CI: [0.58] - [(1.39], p = 0.63, I²=0.00%). Wound dehiscence was marginally less common in the one miniplate group (OR=0.52, 95% CI: [0.28] - [0.98], p = 0.04, I²=54.34%). The probability of scarring formation (OR=0.13, 95% CI: [0.05] - [0.32], p = 0.00, I²=0.00%) and hardware failure (OR=0.36, 95% CI [0.21] - [0.62], p = 0.00, I²=29.33%) were statistically significantly higher in the two miniplates arm.

CONCLUSION

One miniplate fixation and two miniplates fixation of mandibular angle fractures have similar results regarding post operative infection, malocclusion, neurosensory dysfunction and pseudoarthrosis formation while wound dehiscence, hardware failure and scarring seem to be more common when two miniplates are used as a fixation technique.

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

Objectives:

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

Methods:

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

Results:

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

Conclusion:

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

Management of mandibular angle fractures through single and two mini-plate fixation systems: Retrospective study of 112 cases

INTRODUCTION

The aim of this paper is to compare the clinical results between the different methods of fixation of standard mini-plates for the management of mandibular angle fractures.

STUDY DESIGN

This was a retrospective analysis study of 196 patients with mandibular angle fractures divided into 3 groups at our hospital 20 august 1953 specialist hospital, which is a referral center between January 2015 and January 2020. The patients were assessed for malocclusion, infection, wound dehiscence, neuro-sensory deficit, mouth opening, stability, operating time, blood loss, and hardware failure. Group (I) comprised 72 men and 40 women with a mean age of 43 years. Group (II) comprised 36 men and 12 women with a mean age of 47 years. Group (II) comprised 29 men and 7 women with a mean age of 33 years. The assessment of surgical outcomes after the last follow-up visit clearly showed a lack of stability in patients group II compared to the other groups. The operating time was reduced in group I compared to Group II/ III. (P = 0.03) The wound dehiscence occurred mostly in Group III unless it was statistically no significant. The infection events occurred in 36 patients of the sample, which was not statistically significant (Table 4).

DISCUSSION

Fractures of the mandibular angle represent 23-42% of all mandibular fractures, in our context road accidents followed by aggression are the most frequent mechanisms found. A various types of treatment approaches for the treatment of angular fractures have been described. Our analysis revealed that surgical time and complication rate has been reduced when using the Group I technique compared to the other groups.

CONCLUSION

The use of the monocortical external oblique miniplate provides the best results. Successful treatment of mandibular fractures depends on stability in the ideal anatomical position since abnormal mobility at the fracture site will lead to non-union, malocclusion, and infection.

High resolution MRI for quantitative assessment of inferior alveolar nerve impairment in course of mandible fractures: an imaging feasibility study

The purpose of this study was to evaluate a magnetic resonance imaging (MRI) protocol for direct visualization of the inferior alveolar nerve in the setting of mandibular fractures. Fifteen patients suffering from unilateral mandible fractures involving the inferior alveolar nerve (15 affected IAN and 15 unaffected IAN from contralateral side) were examined on a 3 T scanner (Elition, Philips Healthcare, Best, the Netherlands) and compared with 15 healthy volunteers (30 IAN in total). The sequence protocol consisted of a 3D STIR, 3D DESS and 3D T1 FFE sequence. Apparent nerve-muscle contrast-to-noise ratio (aNMCNR), apparent signal-to-noise ratio (aSNR), nerve diameter and fracture dislocation were evaluated by two radiologists and correlated with nerve impairment. Furthermore, dislocation as depicted by MRI was compared to computed tomography (CT) images. Patients with clinically evident nerve impairment showed a significant increase of aNMCNR, aSNR and nerve diameter compared to healthy controls and to the contralateral side (p < 0.05). Furthermore, the T1 FFE sequence allowed dislocation depiction comparable to CT. This prospective study provides a rapid imaging protocol using the 3D STIR and 3D T1 FFE sequence that can directly assess both mandible fractures and IAN damage. In patients with hypoesthesia following mandibular fractures, increased aNMCNR, aSNR and nerve diameter on MRI imaging may help identify patients with a risk of prolonged or permanent hypoesthesia at an early time.

Postoperative Complications Associated With Different Fixation Methods of Isolated Mandibular Angle Fractures

The objective of this study was to review the medical records of patients with a history of mandibular angle fracture who were attended at the Service of Oral and Maxillofacial Surgery and Traumatology of FOAr/UNESP in the last 5 years. The data collected were subjected to chi-squared test (significance level of 5%). The authors reviewed 19 medical records. The main cause was physical aggression (58.00%), but with no statistical difference in relation to the other etiologies (P > 0.05). Regarding the type of fixation, one 2.0-mm system plate associated with one 2.4-mm system plate and the fixation using only two 2.0-mm system plates were used in 7 patients each. The fixation method with a monocortical plate at the upper border was used in 5 patients. However, there was no statistically significant difference in the frequency of complications among the 3 fixation methods used (P > 0.05). In 52.64% of the patients, the third molar was removed intraoperatively. Despite this, there was no statistically significant difference in the frequency of complications when the third molar was in the fracture line or when it was removed postoperatively (P > 0.05). The complications observed were dehiscence associated with pain (44.44%), trismus (22.22%), infection (22.22%), and presence of bone spicules (11.11%). However, no statistical differences were observed between the frequency of different types of complications (P = 0.779). In the sample studied, there were no differences in the frequency of complications among the fixation methods applied.

Evaluation of postoperative complications according to treatment of third molars in mandibular angle fracture

Objectives

The aim of this study was to evaluate the implication of third molars in postoperative complications of mandibular angle fracture with open reduction and internal fixation (ORIF).

Materials and Methods

Data were collected on patients who presented with mandibular angle fracture at our Department of Oral and Maxillofacial Surgery between January 2011 and December 2015. Of the 63 total patients who underwent ORIF and perioperative intermaxillary fixation (IMF) with an arch bar, 49 patients were identified as having third molars in the fracture line and were followed up with until plate removal. The complications of postoperative infection, postoperative nerve injury, bone healing, and changes in occlusion and temporomandibular joint were evaluated and analyzed using statistical methods.

Results

In total, 49 patients had third molars in the fracture line and underwent ORIF surgery and perioperative IMF with an arch bar. The third molar in the fracture line was retained during ORIF in 39 patients. Several patients complained of nerve injury, temporomandibular disorder (TMD), change of occlusion, and postoperative infection around the retained third molar. The third molars were removed during ORIF surgery in 10 patients. Some of these patients complained of nerve injury, but no other complications, such as TMD, change in occlusion, or postoperative infection, were observed. There was no delayed union or nonunion in either of the groups. No statistically significant difference was found between the non-extraction group and the retained teeth group regarding complications after ORIF.

Conclusion

If the third molar is partially impacted or completely nonfunctional, likely to be involved in pathologic conditions later in life, or possible to remove with the plate simultaneously, extraction of the third molar in the fracture line should be considered during ORIF surgery of the mandible angle fracture.