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

Is Open Reduction Internal Fixation Using Titanium Plates in the Mandible as Successful as We Think?

ABSTRACT

Titanium plats are the gold-standard for fracture fixation. Titanium is considered biocompatible, corrosion resistant with an elasticity-modulus closest to bone. Nonetheless, titanium plates are not always as inherent as hoped. The authors investigated morbidity associated with titanium plates in mandibular fractures. A retrospective study of mandibular fractures treated between 2000 and 2018 using internal-fixation was conducted. Data included age, gender, complications, and location. Predictor-variable was location. Outcome-variable was plate removal. A total of 571 patients were included, 107 resulted in plate removal (18.7%). Body was the most prevalent location of fracture (29.3%). Symphysis/para-symphysis showed the highest removal rate (24.1%), followed by body and angle (21.3/19.8%). A total of 23.4% of double-plating cases resulted in plate removal, upper-border in 15% and lower-border in 8.8%, all reconstruction-plates. Exposure was the most frequent complication leading to removal. Although titanium plates are the gold standard, almost every fifth patient returns for plate removal. Age-distribution emphasizing 41 to 50 with decrease towards extremities may imply better healing in the young and soft-tissue elasticity and less complaints in the elderly. Significantly more complications in double-plating compared to lower border suggests proximity to the oral-cavity as a risk-factor for removal. Complication rates and patterns are not negligible and perhaps should encourage clinicians to consider using biodegradable-systems for upper-border plates.

Treatment Delay Impact on Open Reduction Internal Fixation of Mandibular Fractures: A Systematic Review

BACKGROUND

The impact of mandible fracture treatment delay has been contested in the literature for decades, with conventional wisdom favoring earlier surgical treatment to prevent postoperative complications, primarily infection. Through a systematic review of all available evidence, this study aims to determine whether delay to open reduction and internal fixation of traumatic mandibular fractures influences outcomes.

METHODS

MEDLINE, EMBASE, CINAHL, and Web of Science were systematically searched for English language literature pertaining to the above research question and screened in duplicate. Methodological quality scoring was performed using MINORS criteria. Qualitative and quantitative findings from relevant studies are presented.

RESULTS

Twenty eligible studies including 2,671 patients had open reduction internal fixation, with or without adjunct mandibulomaxillary fixation. All studies were observational cohort or case-control studies of low methodological quality with a mean MINORS score of 6.5 of 16 (40.6%) for noncomparative studies and 11.2 of 24 (46.7%) for comparative studies. Only 5 of 20 (25%) studies recommended earlier treatment. Due to insufficient reporting of data and study heterogeneity, the impact of treatment delay on complications could not be quantitatively analyzed.

CONCLUSIONS

There is substantial heterogeneity and no consensus on the definition of "early" versus "delayed" surgical treatment for patients with traumatic mandibular fractures. The majority of included studies do not make a recommendation for earlier treatment. Future, well-designed prospective studies are essential to determine if there is an optimal surgical treatment delay of mandibular fractures that mitigates the risk of infectious and noninfectious complications.

Treatment of Mandibular Angle Fractures with Single Three-Dimensional Locking Miniplates without Maxillomandibular Fixation: How Much Fixation Is Required?

The aim of this simple nonrandomized and observational study was to evaluate the efficacy of single three-dimensional (3D) plate for the treatment of mandibular angle fractures without maxillomandibular fixation. A total of 30 patients with noncomminuted fractures of mandibular angle requiring open reduction and internal fixation were included in the study. All the patients were treated by open reduction and internal fixation using single 3D titanium locking miniplate placed with the help of transbuccal trocar or Synthes 90-degree hand piece and screw driver. 3D locking titanium miniplates used in our study was four-holed, box-shaped plate, and screws with 2 mm diameter and 8 mm length. The following clinical parameters were assessed for each patient at each follow-up visit: pain (visual analog scale: 0-5), swelling (visual analog scale: 0-5), mouth opening, infection, paresthesia, hardware failure (plate fracture), occlusal discrepancies, and mobility between fracture fragments. A significant decrease in pain level was seen during the follow-up visits. No statistically significant changes were seen in swelling, but mouth opening increased in the subsequent visits. Also better results were seen in terms of fracture stability and occlusion in the postoperative period. Two cases of infection and two cases of hardware failure were noted in sixth postoperative week. 3D plating system is an easy to use alternative to conventional miniplates to treat mandibular angle fractures that uses lesser foreign material, thus reducing the operative time and overall cost of the treatment. Better fracture stability and occlusion was also achieved using the 3D plating system.

Efficacy and Safety of Biodegradable Osteofixation Devices in Oral and Maxillofacial Surgery: a Systematic Review

The use of osteofixation devices should be evidence-based if uncomplicated bone healing is to be achieved. Numerous studies describe and claim the advantages of biodegradable over titanium devices as a bone fixation method. Here, we systematically review the available literature to determine the clinical efficacy and safety of biodegradable devices compared with titanium devices in oral and maxillofacial surgery. In addition, related general aspects of bone surgery are discussed. We conducted a highly sensitive search in the databases of MEDLINE (1966–2005), EMBASE (1989–2005), and CENTRAL (1800–2005) to identify eligible studies. Eligible studies were independently evaluated by two assessors using a quality assessment scale. The study selection procedure revealed four methodologically ‘acceptable’ articles. Owing to the different outcome measures used in the studies, it was impossible to perform a meta-analysis. Therefore, the major effects regarding the stability and morbidity of fracture fixation using titanium and biodegradable fixation systems were qualitatively described. Any firm conclusions regarding the fixation of traumatically fractured bone segments cannot be drawn, due to the lack of controlled clinical trials. Regarding the fixation of bone segments in orthognathic surgery, only a few controlled clinical studies are available. There does not appear to be a significant short-term difference between titanium and biodegradable fixation systems regarding stability and morbidity. However, definite conclusions, especially with respect to the long-term performance of biodegradable fixation devices used in maxillofacial surgery, cannot be drawn. Abbreviations: CENTRAL, Cochrane Central Register of Controlled Trials; MeSH, Medical Subject Heading; VAS, Visual Analogue Scale; and W, weight.

Early Experience with Biodegradable Fixation of Pediatric Mandibular Fractures

This clinical study aims to evaluate the stability and efficiency of biodegradable self-reinforced poly-l/dl-lactide (SR-PLDLA) plates and screws for fixation of pediatric mandibular fractures. The study included 12 patients (3-12 years old) with 14 mandibular fractures. They were treated by open reduction and internal fixation by SR-PLDLA plates and screws. Maxillomandibular fixation was maintained for 1 week postoperatively. Clinical follow-up was performed at 1 week, 6 weeks, 3 months, and 12 months postoperatively. Radiographs were done at 1 week, 3 months, and 12 months postoperatively to observe any displacement and fracture healing. All fractures healed both clinically and radiologically. No serious complications were reported in the patients. Normal occlusion was achieved in all cases. Biodegradable osteofixation of mandibular fractures offers a valuable clinical solution for pediatric patients getting the benefit of avoiding secondary surgery to remove plates, decreasing the hospital stay, further painful procedures, and psychological impact.

Comparison of resorbable plates and titanium plates for fixation stability of combined mandibular symphysis and angle fractures

OBJECTIVES

We compared resorbable plates with titanium plates for treatment of combined mandibular angle and symphyseal fractures.

MATERIALS AND METHODS

Patients with mandibular angle and symphysis fractures were divided into two groups. The control (T) group received titanium plates while the experimental (R) group received resorbable plates. All procedures were carried out under general anesthesia using standard surgical techniques. We compared the frequency of wound dehiscence, development of infection, malocclusion, malunion, screw breakage, and any other technical difficulties between the two groups.

RESULTS

Thirteen patients were included in the R group, where 39 resorbable plates were applied. The T group consisted of 16 patients who received 48 titanium plates. The mean age in the R and T groups was 28.29 and 24.23 years, respectively. Primary healing of the fractured mandible was obtained in all patients in both groups. Postoperative complications were minor and transient. Moreover, there were no significant differences in the rates of various complications between the two groups. Breakage of 3 screws during the perioperative period was seen in the R group, while no screws or plates were broken in the T group.

CONCLUSION

Resorbable plates can be used to stabilize combined mandibular angle and symphysis fractures.

Comparative evaluation of bite forces in patients after treatment of mandibular fractures with miniplate osteosynthesis and internal locking miniplate osteosynthesis

Aims and Objectives:

The aim of present study was to compare the stability of fractured mandibular fragments under functional load, when fixed with conventional miniplate and internal locking miniplate.

Materials and Methods:

Bite force (in kg) recorded in twenty mandible fractured patients and fifty normal healthy individuals. Bite force was measured at incisor and molar regions. Comparative evaluation of bite force generated was performed between 10 cases treated with conventional miniplates and 10 cases treated with internal locking miniplates. Bite force generated by patients in mandibular fracture between symphysis and the angle of mandible was recorded in incisor and molar regions preoperatively. The fracture fragments were fixed using the above fixation techniques. Then same recording was undertaken on the 7^th, 14^th, 21^st, 28^th, and 90^th days postoperatively.

Results:

Bite force generated by patients treated with locking plates at the 7^th, 14^th, 21^st, 28^th, and 90^th postoperative days was significantly higher as compared to those in patients treated with miniplates.

Conclusion:

It was observed in our study that the locking plate/screw system offers significant advantages over the conventional plating system. There are no intraoperative difficulties associated with placement of the plate.

Study of Efficacy and the Comparison Between 2.0 mm Locking Plating System and 2.0 mm Standard Plating System in Mandibular Fractures

PURPOSE

The purpose of this study was to evaluate the efficacy and comparison between 2.0 mm locking plate system and 2.0 mm Champy's titanium mini plating system in mandible fractures.

MATERIALS AND METHODS

A total of 20 patients with mandibular fractures were selected and divided into two groups A and B on randomized basis. Group A was treated with open reduction internal fixation using 2.0 mm locking plates and group B with 2.0 mm Champy's titanium miniplates. All patients were followed up for 12 weeks postoperatively.

RESULTS

Results of the study show less screw loosening, less precision in plate adaptation and less alteration of the osseous or occlusal relationship upon screw tightening in group A. Chi square test was applied to compare the results between the two groups. Statistical analysis did not show significant difference of incidence of malocclusion between the two groups (p value = 0.606). Statistical analysis using un-paired t test showed significant difference of working time between the two groups (p value = 0.00296). When comparing the overall complication rates according to plates used, the χ(2) test showed no statistically significant difference between the locking and nonlocking plates (p > 0.05).

CONCLUSION

It is observed in our study that the locking plate/screw system offers significant advantages over the conventional plating system. The precise adaptation required for using conventional plates is not needed when this locking plate/screw system is used. Locking plate/screw system provides better stability than the conventional plate/screw system.

A comparative analysis of the efficacy of cortical screws as lag screws and miniplates for internal fixation of mandibular symphyseal region fractures: a randomized prospective study

The management of facial trauma is one of the most rewarding and demanding aspects of oral and maxillofacial surgery. Being the most prominent mobile bone of the facial skeleton, mandible fracture occurs more frequently than any other fracture. In this study, open reduction and internal fixation was performed for isolated mandibular symphyseal region fractures using cortical screws (as lag screws) in 40 patients and using miniplates in 40 patients. Clinical and radiological evaluations were made at 6 months postoperatively. Primary stability of fracture segments, postoperative swelling, restricted lip mobility, infection, wound dehiscence, implant removal, and mal-union or non-union of fracture segments was evaluated. Primary stability was achieved in 100% of cases treated with cortical screws, whereas for patients treated with miniplates, 97.5% attained primary stability, while one case (2.5%) showed persistent clinical mobility. Postoperative complications were noted in 13 (16.25%) of the total 80 patients. The duration of postoperative swelling was less in patients treated with cortical screws compared to patients treated with miniplates. It is concluded that cortical screw fixation is an effective procedure for the treatment of symphyseal region fractures, but the procedure is somewhat technically sensitive.

Mandibular fracture scoring system: for prediction of complications

INTRODUCTION

Mandibular fractures are one of the most commonly encountered injuries in trauma clinics. Although several widely accepted classification systems exist, these are mostly region specific, differ in the classification criteria used, and are sometimes only correlated with specific treatment modalities, thereby making it impossible to uniformly and comprehensively document facial fracture patterns. In this study, we developed a modified scoring system for mandibular fractures and analyzed the relationship between scoring of fractures that were treated and the incidence of complications after surgical treatment.

MATERIALS AND METHODS

To evaluate the suitability of the proposed scoring system, a prospective study on a series of 116 patients was performed. All the fractures were classified using the proposed scoring system. The scoring was based on clinical and radiological evaluation of each fracture. Patients were followed up postoperatively for presence of complications.

RESULTS

A good correlation between the proposed scoring system and the incidence of complications was detected.

DISCUSSION

This scoring system for mandibular fractures facilitates an objective and standardized assessment of the degree of severity of a fracture, thereby allowing for systematic evaluation of facial fracture outcomes, including assessment of complications. However, it is our understanding that a multicenter study should be performed before the effectiveness of the proposed classification can be clearly stated.

Small and large titanium plates are equally effective for treating mandible fractures

PURPOSE

The use of small titanium plates for the management of mandibular fractures continues to be a source of controversy because of their load-sharing properties. The purpose of the present study was to determine whether the use of small plates for mandibular fractures is as efficacious as large plates in a large level I trauma center.

MATERIALS AND METHODS

Consecutive subjects presenting with mandibular fractures were randomly allocated to the use of either small plates (group 1) or large plates (group 2). The primary predictor variable was the plate size. The primary outcome variable was fracture union. The secondary outcomes included complications and operative time. Statistical analysis was performed using the Wilcoxon rank sum test for ordinal and continuous variables and the χ(2) test or Fisher exact test for proportions.

RESULTS

A total of 127 consecutive subjects with a fracture of the mandible were enrolled in the study. Of the 127 subjects, 53 completed the required follow-up of at least 6 weeks. There was no difference in the rate of fracture union between the 2 groups (P = .95).

CONCLUSIONS

The study findings suggest that the use of small plates and monocortical screws for mandibular fractures results in favorable outcomes compared with using larger plates and bicortical screws.

Can an arch bar replace a second lag screw in management of anterior mandibular fractures?

PURPOSE

To evaluate the efficacy of using a single lag screw combined with an arch bar in the management of anterior mandibular fractures and to compare this method with the traditional application of 2 lag screws.

MATERIALS AND METHODS

We designed and implemented a randomized clinical trial and enrolled a sample of patients with anterior mandibular fractures. Twenty adult male patients were randomly divided into 2 equal groups according to the number of lag screws used for fracture fixation after securing the occlusion with intermaxillary fixation. In group A, the fractures were treated using 2 lag screws. In group B, the fractures were treated using a single lag screw and an arch bar on the teeth, spanning the fracture line. Clinical and radiographic evaluations were used to evaluate the efficacy of each fixation method immediately and at 2 and 4 months postoperatively.

RESULTS

The clinical examination showed stable fixation with no mobility or infection in all cases. One patient in group A showed a slight occlusal discrepancy that was managed with occlusal adjustment. The pretraumatic occlusal relationship of all other patients was re-established. Postoperative radiographs showed properly reduced fracture segments with gradual bone healing. No significant difference was noted (P > .05) between the 2 groups in the development of postoperative complications.

CONCLUSIONS

The use of 1 lag screw in conjunction with an arch bar across the fracture line is rigid and stable enough to manage anterior mandibular fractures without the need for supplemental intermaxillary fixation. The use of a single lag screw offers several advantages compared with the traditional use of 2 lag screws. These advantages include decreased cost, use of materials, healing time, and risk of associated morbidity.

Skeletal stability and morbidity with self-reinforced P (L/DL) LA resorbable osteosynthesis in bimaxillary orthognathic surgery

INTRODUCTION

We present a retrospective study of 30 consecutive cases of bimaxillary orthognathic surgery with biodegradable self-reinforced poly-L/DL-lactide plates and tacks, for the same indication of Angle class III malocclusion. We reported the skeletal stability and morbidity at 1 year after surgery.

PATIENTS AND METHODS

All patients underwent bimaxillary procedure. We used self-reinforced poly-L/DL lactic acid copolymer. Stabilization of Lefort I osteotomy was achieved by four plates L-shaped. Sagittal split osteotomies were fixed by two straight-plates. Lateral cephalograms were taken before (T0), soon after (T1) and more than 1 year after surgery (T2). Eight standard landmarks and four angular measurements were taken into account. All differences of the landmarks and angles were measured at T1 and T2. The regular clinical follow-up was scheduled for a minimum period of 1 year.

RESULTS

The mean advanced maxillary was 3.33 mm and the mean mandibular setback was 6.13 mm. The mean mandibular relapse was 2.2 mm (non-significant). Horizontal maxilla mean variation was 0.8 mm at 1 year at A-point. Vertical maxilla stability depends on maxillary movements: impaction stability is better as an isolated advancement or associated with pull-down movement. We found six inflammatory reactions and two of them need the removal of the plates.

CONCLUSION

Bimaxillary orthognathic procedure with bioresorbable osteosynthesis is a reliable and reproducible method. Angle class III malocclusions could be entirely and successfully managed with bioresorbable osteosynthesis. The stability and suites at 1 year are comparable to titanium osteosynthesis.

Self-drilling and self-tapping screws: an ultrastructural study

OBJECTIVE

The aim of the current study was to compare self-drilling and self-tapping screws with regard to bone contact and the production of bone debris using scanning electron microscopy.

MATERIALS AND METHODS

Three New Zealand rabbit calvariae were used. Self-tapping and self-drilling screws were inserted into the outer surface of the skull with and without saline solution irrigation. All screws were 5 mm in length and were inserted until their tips projected through the endosteal side. Sixteen screws were used--8 with a head diameter of 1.5 mm and 8 with 2.0 mm. All self-tapping screws were inserted through a drill bit hole (1.6 mm for 2.0-mm screws and 1.3 mm for 1.5-mm screws).

RESULTS

There was no damage to the screws after insertion. Bone damage occurred when irrigation was not used during the installment of the self-tapping screws. Bone debris formed during the installment of the self-drilling screws, which is considered beneficial.

CONCLUSIONS

Because the insertion of self-drilling screws is performed with manual pressure, irrigation is not essential. Unlike the drilling that occurs with self-tapping screw, the bone debris formed with self-drilling screws is not the result of the heat generated, but rather the result of biologically active bone tissue capable of reacting with the screw and improving its performance. The animal model used proved highly appropriate for comparisons with human beings because the bone structures of the head have the same density and thickness.

Five-year retrospective study of mandibular fractures in Freiburg, Germany: incidence, etiology, treatment, and complications

PURPOSE

To evaluate current trends in maxillofacial trauma, a retrospective review of mandibular fractures at a German university hospital was carried out.

PATIENTS AND METHODS

In this retrospective study, records of 444 patients with mandibular fractures between 2000 and 2005 at the Department of Oral and Maxillofacial Surgery, University Hospital of Freiburg, Germany, were reviewed. A total of 444 patients presented with 696 mandibular fractures.

RESULTS

Three hundred twenty-nine (74%) of the fractures occurred in male and 115 (26%) in female patients (2.9:1). One hundred forty-two fractures (32%) resulted from road traffic accidents, 126 from fights (28%), and 116 from falls (26%). Forty-four fractures were caused by sport accidents (10%) and 16 by pathologic fractures (4%). The mandibular condyle area was the most common fracture site, with 291 fractures (42%), followed by 144 fractures of the symphyseal and parasymphyseal area (21%) and 141 angle fractures (20%). Combined fractures were found in nearly half of the cases. Five hundred seventy-nine (83%) of patients with mandibular fractures were treated by surgical intervention, 117 (17%) of patients conservatively. Regarding the surgical treatment, 561 (65%) miniplates, 247 (29%) locking plates, and 51 (6%) lag screws were used. Complications, such as postoperative infections, abscesses, and osteomyelitis appeared in 66 (9%) cases.

CONCLUSION

We concluded that osteosynthesis of mandibular fractures by miniplates and locking plates are both reliable.

Prevalence of Postoperative Complications After Orthognathic Surgery: A 15-Year Review

PURPOSE

This study was conducted to determine the prevalence of postoperative complications after orthognathic surgery and evaluate the use of antibiotic prophylaxis in relation to the infection rate.

PATIENTS AND METHODS

All patients undergoing orthognathic procedures between 1990 and 2004 were studied retrospectively by retrieving their individual medical records. Demographic data, intraoperative data (specific orthognathic procedures and duration of operation), and postoperative data (type and duration of antibiotic prophylaxis and presence of postoperative complications) were recorded. Patients noted to have suffered any postoperative complications were studied in detail, and various factors, including gender, age, duration of operation, and use of prophylactic antibiotics, were analyzed using statistical tests in relation to postoperative infection.

RESULTS

A total of 2,910 orthognathic procedures were performed on 1,294 consecutive patients in the 15-year period, with 1,070 patients undergoing bimaxillary procedures and 224 patients undergoing single-jaw surgery. The orthognathic surgery-related complication rate was 9.7%, of which 7.4% was related to postoperative infection. Of the cases of infection, 58.3% were acute infection and 41.7% were chronic infection. Patients who received a single preoperative dose of antibiotics had a significantly higher infection rate (17.3%) than those who received postoperative antibiotics for various durations.

CONCLUSIONS

The prevalence of infection after orthognathic surgery was relatively low given the complexity of the procedures. No particular orthognathic procedure was more susceptible to infection. A preoperative dose of prophylactic antibiotics together with at least 2 days of postoperative doses was useful in reducing the infection rate compared with only a single dose of prophylactic antibiotics.

Reasons for miniplate removal following maxillofacial trauma: a 4-year study

INTRODUCTION

There is still no consensus on the need for routine removal of titanium miniplates in the maxillofacial skeleton. The purpose of this 4-year prospective study was to evaluate the reasons for removal of titanium miniplates ("2.0mm") following maxillofacial trauma.

MATERIAL AND METHODS

Records of 280 patients were evaluated concerning the number of plates inserted, the site of plating, the number of patients in whom plates were removed, the site of removal and the reasons for which removal of plates was indicated.

RESULTS

In the 280 patients with facial trauma, 599 miniplates were used during this period. Thirty-seven miniplates were removed from 27 of these patients. The main causes for removal were infection and exposure of the plate in the oral cavity, patients' request and/or the plates being palpable. The nasofrontal region, the area around the anterior wall of the antrum and the body of the mandible proved to be the commonest regions where plate removal was required.

CONCLUSION

The number of miniplates removed was small but not insignificant. There is no evidence from this study to support advice for the routine removal of titanium miniplates from the maxillofacial skeleton.

Epidemiological analysis of maxillofacial fractures in Brazil: a 5-year prospective study

OBJECTIVE

The aim of this study was to assess the characteristics of maxillofacial fractures in the Piracicaba region of Brazil during a 5-year period and to delineate comparisons with worldwide facial fracture patterns.

STUDY DESIGN

A descriptive statistical analysis was developed based on data collected using a specifically designed clinical survey of all patients who attended the Division of Oral and Maxillofacial Surgery at the Piracicaba Dental School from 1999 to 2004. Information regarding age, gender, etiology, and type of maxillofacial injury and its associated lesions were evaluated. In addition, treatment modalities and complication rates during patient follow-up were assessed.

RESULTS

A total of 1024 patients presenting 1399 maxillofacial fractures were analyzed. Patients' ages ranged from 0 to 88 years (mean age, 28 +/- 16.4 years). The ratio of men to women was 4:1. Most fractures were caused by traffic accidents (45%), followed by assaults (22.6%), falls (17.9%), sports accidents (7.8%), and work accidents (4.5%). The prevalent anatomic regions of facial fractures (in percentages) were the mandible (44.2%), the zygomatic complex (32.5%), and the nasal bones (16.2%). Associated systemic lesions were found in 41.9% of patients, with prevalence for injuries to the upper (24.1%) and lower limbs (15.4%). Patient management was considered to be conservative in 490 patients (47.9%), and surgical therapy was performed in 493 patients (48.1%), of whom 399 (80.9%) were treated with open reduction and rigid internal fixation. Complications occurred in 76 patients (7.4%), mainly due to infection and malocclusion.

CONCLUSION

The findings of this study indicated that epidemiological research of maxillofacial fractures allows the presentation patterns of the most affected individuals and the nature of their lesions to be outlined according to the region evaluated. Furthermore, treatment evaluation and complication rate analysis permits a more realistic interpretation of how patients should be managed.

[Quantitative evaluation of thermosensitivity in patients with mandibular fractures]

AIM

The temperature and pain thresholds of 30 patients with mandibular fractures were evaluated with a specially developed measuring device in a prospective study to examine neurosensory disturbances of the inferior alveolar nerve (IAN).

PATIENTS AND METHODS

Measurements in 30 patients with 45 mandibular fractures were done before, immediately after, and over the course of half a year after operation. Outcomes of the thermosensitivity measurement (TSM) were compared to the results of the two point discrimination (2-PD) test, sharp/blunt test (SBT), and questioning the patients about their subjective feelings (SF).

RESULTS

Post-traumatically, neurosensory testing revealed up to 2.8 degrees C (mean) increased thresholds as compared with the intact side. By contrast, post operative diagnostics clearly revealed up to 8.1 degrees C (mean) increased thresholds. Compared with the clinical sensory tests, the post-therapeutic (3-6 months postoperative) measurements with the TSM device proved a resensitization and threshold decrease by up to 3 degrees C. We found more exact and reproducible results of the TSM in comparison to those of the 2-PD and SBT for the evaluation of sensory disturbances of the IAN. Close agreements between the results of the TSM and the SF could be detected.

CONCLUSION

Because of its sensitivity and accuracy in the quantitative detection of temperature and pain thresholds, the TSM is particularly suitable for evaluating neurosensory deficits and monitoring their progression.

Symptomatic Plate Removal in Maxillofacial Trauma

This study reviewed the fate of titanium plates used to correct maxillofacial trauma in 76 patients to define risk factors for plate removal. Medical records of 76 consecutive patients at a single institution, over a 10-year period, were retrospectively reviewed. Variables included age, sex, trauma type, diagnosis, fracture type, fracture diagnosis, plate location, surgical approach, and reasons for plate removal. Fracture diagnosis was described as panfacial (42%), blowout (3%), midface (28%), zygoma (26%), mandible angle (6%), ramus (7%), and symphysis (9%). All plate removals according to fracture diagnosis were in the mandible angle (30%) and symphysis (20%). When plate location was reviewed, 68% of the plates were placed in the upper and midface and 32% were placed in the mandible. Specifically, plates were placed in the frontozygomatic suture (18%), zygomaticomaxillary suture (19%), infraorbital rim (14%) and mandible symphysis (15%), mandible angle (9%), piriform (6%), nasal (5%), mandible ramus (4%) and body (4%), zygoma (2%), and frontal (2%). Of 163 plates that were placed, 6 plates (3.7%) were removed. Three (12%) of the symphysis plates and 3 (20%) of the angle plates were removed. Among all variables, only fracture diagnosis (P = 0.01) and plate location (P = 0.01) were statistically significant in plate removal. Five plates were removed for abscess/infection; 1 plate was removed for osteomyelitis. Further review revealed that 4 out of 6 plates removed involved synchronous mandible fractures. Most infections after maxillofacial trauma occur in the mandible, and often these infections are the main reason for plate removal. More vigilance is needed in the treatment of mandible angle and symphyseal fractures, especially if there are synchronous fractures, to prevent infection, plate removal and subsequent malunion.

A randomized controlled trial of resorbable versus titanium fixation for orthognathic surgery

OBJECTIVES

To determine any differences in the intra- and postoperative morbidities and complications between resorbable and titanium plating systems for fixation in orthognathic surgery.

STUDY DESIGN

This prospective randomized clinical trial was conducted in the Oral and Maxillofacial Surgery unit of the University of Hong Kong. Patients with dentofacial deformities were randomly assigned into the titanium and resorbable fixation groups. Intraoperative data such as the surgical procedures, time for fixing each plate, and number of broken plates and screws were recorded. Subjective and objective parameters related to clinical morbidities were assessed postoperatively.

RESULTS

A total of 60 patients with 177 osteotomies were included in this study. Eighty-seven osteotomies fixated with 196 titanium plates and 784 titanium screws were performed in 30 patients, whereas 90 osteotomies fixated with 165 resorbable plates and 658 resorbable screws were done in another 30. The postoperative infection rate was 1.53% (3/196) and 1.82% (3/165) in the titanium and resorbable fixation groups, respectively. These infections were mainly due to loose screws and wound dehiscence. The plate exposure rate was 1.02% (2/196) for the titanium group and 1.21% (2/165) for the resorbable group. The plate removal rate in the titanium and resorbable groups was 1.53% (3/196) and 3.63% (6/165), respectively. Statistically significant difference was shown in the plating time of step (mandibular body) and Hofer (mandibular subapical) osteotomies. There was no significant difference in the subjective clinical parameters such as wound discomfort, clinical stability of the osteotomy segments, palpability of plate, and overall satisfaction of the results between the 2 fixation groups. Similarly, objective parameters including wound dehiscence, rate of infection, plate exposure, occurrence of sinus tract, and palpability assessed by surgeons in both groups also showed no significant difference.

CONCLUSION

Bioresorbable fixation devices offer similar function as titanium in fixation for orthognathic surgery and do not impose an increase in the clinical morbidities.

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.

Le Fort I miniplate osteosynthesis: a randomized, prospective study comparing resorbable PLLA/PGA with titanium

The aim of this study was to compare the use of resorbable osteosynthesis material (LactoSorb) with titanium osteosynthesis for the fixation of Le Fort I osteotomies with respect to long-term stability and morbidity. To achieve exact cephalometric measures, five tantalum micro implants were inserted in the maxilla during surgery. A total of 60 patients undergoing a non-segmented Le Fort I osteotomy were randomized to one of the treatments and were followed for 1 year postoperatively. For the osteotomies fixated with LactoSorb, the lateral cephalometric analysis demonstrated a statistically significant difference in the vertical position of the maxilla after 6 weeks as the position became more superior compared with the postoperative situation (mean change of 0.6 mm). In the titanium group no significant changes in position were observed. There were no statistically significant changes in the position of the maxilla from 6 weeks to 12 months in either of the treatment groups. The changes in maxillary postion were not clinically noticeable in either of the treatment groups, and all treatments were completed with satisfactory results. There were two cases of infection and wound dehiscence in the LactoSorb group, whereas titanium osteosynthesis was more often palpable after 6-12 months and required surgical removal in three cases.

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.

Complications of mandibular fractures in an urban teaching center

PURPOSE

In this study, we compared the complications associated with open and closed treatment of mandibular fractures in an urban teaching center over a 4-year period.

PATIENTS AND METHODS

We conducted a retrospective review of mandibular fracture morbidity associated with treatment by the oral and maxillofacial surgery service between 1996 and 2000. A total of 721 fractures were recorded, with 594 fractures available for review. Perioperative and postoperative complications were assessed by reviewing patient charts, operative reports, and radiographs. Complications were classified by location, type of complication, and treatment modality. Standard statistical tests were used to assess differences between the groups.

RESULTS

Of the 594 fractures available for review, a total of 79 fractures were noted to have had a complication (13.3%). One hundred five complications were observed in the group of 79 fractures due to more than one complication being associated with a specific fracture (15.8%). Closed reductions accounted for the largest treatment group, representing 341 fractures with 26 complications (7.6%). Miniplate fixation was used in 97 cases, with 23 complications (23.7%). Mandibular plates with or without a superior border miniplate were used in 140 fractures, with 28 complications (20%). The most common complication was wound infection, which occurred in 35 fracture sites, followed by nonunion, which occurred at 30 sites.

CONCLUSION

In an urban area with a high prevalence of poor living conditions, substance abuse, and poor patient compliance, the treatment of mandibular fractures by closed reduction resulted in the least number of postoperative complications in all anatomic regions of the mandible. The mandibular angle fracture had the highest overall morbidity rate.

Fixation of mandibular fractures with 2.0-mm miniplates: review of 191 cases

PURPOSE

Our goal was to study the use of 2.0-mm miniplates for the fixation of mandibular fractures.

PATIENTS AND METHODS

Records of 191 patients who experienced a total of 280 mandibular fractures that were treated with 2.0-mm miniplates were reviewed. One hundred twelve of those patients, presenting 160 fractures, who attended a late follow-up were also clinically evaluated. Miniplates were used in the same positions described by AO/ASIF. No intermaxillary fixation was used. All patients included had a minimum follow-up of 6 months. Demographic data, procedures, postoperative results, and complications were analyzed.

RESULTS

Mandibular fractures occurred mainly in males (mean age, 30.3 years). Mean follow-up was 21.92 months. The main etiology was motor vehicle accident. The most common fracture was the angle fracture (28.21%). Twenty-two fractures developed infection, for an overall incidence of 7.85%. When only angle fractures are considered, that incidence is increased to 18.98%. Although only 1 patient (0.89%) described inferior alveolar nerve paresthesia, objective testing revealed sensitivity alterations in 31.52% of the patients who had fractures in regions related to the inferior alveolar nerve. Temporary mild deficit of the marginal mandibular branch was observed in 2.56% of the extraoral approaches performed and 2.48% presented with hypertrophic scars. Incidence of occlusal alterations was 4.0%. Facial asymmetry was observed in 2.67% of the patients, whereas malunion incidence was 1.78%. Fibrous union, mostly partial, occurred in 2.38% of the fractures, but only 1 of those presented with mobility (0.59%). Condylar resorption developed in 6.25% of the fixated condylar fractures. Mean mouth opening was 42.08 mm.

CONCLUSION

The overall incidence of complications, including infections, was similar to those described for more rigid methods of fixation.

A retrospective study of selected oral and maxillofacial fractures in a group of Jordanian children

Objective. The purpose of this study was to review the etiology, incidence, and treatment of selected oral and maxillofacial fractures in children in Jordan. Study Design. This retrospective review of patient records and radiographs was conducted during the 5-year period between 1996 and 2001. Age, gender, etiology, anatomic site, and treatment methods were reviewed. Results. During the 5-year period, 227 patients with 274 maxillofacial fractures were treated. The age range was from 1 to 15 years (mean age, 11.2 years). Of the patients, 70% were male, with the peak incidence rate occurring in the 10-year-old to 12-year-old age group. The mandible was the most frequent bone of fracture, with 169 cases (74.5%), followed by the alveolar process in 28 cases (12.3%), the maxilla in 27 cases (11.9%), and the zygomatic complex in 3 cases (1.3%). Of the fractures, 52% were from accidental falls, 20% from road traffic accidents, 17% from assaults, 8% from sport injuries, and 3% from other causes, such as horse kick. Most patients (82.3%) were treated with closed reduction (45.2% with eyelet wiring and 54.8% with arch bars and intermaxillary fixation). Only 17.7% of patients were treated with open reduction and fixation. All maxillary fractures were treated with orbital and circumzygomatic suspension with interdental wiring and intermaxillary fixation. The 3 cases of zygomatic complex fractures were kept under observation without the necessity of surgical intervention. Conclusion. Accidental falls were found to be the leading cause of maxillofacial fractures in our environment, and males were 3 times more affected than females.

Complications and removal rates of miniplates and screws used for maxillofacial fractures

Complications of miniplates and screws used for maxillofacial fractures were analyzed, and complications were evaluated in relation to fracture site. Motor vehicle accidents were the cause of all fractures in this study. During the last 7 years (1994-2001), noncompressive titanium miniplates and screws were used for stabilization of maxillofacial fractures. In 66 patients, 87 fracture sites were stabilized using 296 miniplates and 1,184 screws. The mean age of the patients was 31 years (age range, 6-64 years). The percentage of male patients was 77% and the percentage of female patients was 23%. Miniplates and screws were used in 6 patients (10%) who were younger than 15 years of age at the time of the surgery. The follow-up period ranged between 3 months and 7 years. The overall miniplate and screw removal rate was 7%. The rates of removal according to the fracture site are as follows: mandible, 4.4%; zygomaticofrontal junction, 1.4%; inferior orbital rim, 0.7%; maxilla, 0.3%; and frontal sinus wall, 0.3%. Removal causes were infection, 2%; extrusion, 1.7%; visibility, 1.4%; pain, 1%; malunion, 0.7%; and miniplate fracture, 0.3%. The minimum time period between insertion and removal was 3 months and the maximum period was 14 months. Infection and extrusion were the main complications for removal of miniplates and screws from the mandible, whereas miniplates and screws were removed from the zygoma because of visibility (zygomaticofrontal region) under the skin in the vast majority of the patients. The maxilla was the least operated region for miniplate and screw removal. In all patients in this study, the preoperative physical symptoms were relieved after miniplate and screw removal. Miniplates and screws are very useful tools in maxillofacial fracture management, but sometimes they have to be removed. In the authors' series, the removal rate was 7%, and this rate can vary with the severity of the trauma and location of the fracture.

Mandibular fractures in Townsville, Australia: incidence, aetiology and treatment using the 2.0 AO/ASIF miniplate system

In 1995 a total of 114 patients presented with 154 mandibular fractures at the Townsville General Hospital, Australia. Fifty-eight (51%) were white, 50 (44%) aboriginal, and six (5%) of other or unknown race. One-hundred-and-twenty-four of the fractures (81%) occurred in male and 30 (19%) in female patients. Most fractures (n= 128, 83%) resulted from fights. The rest being a result of road traffic accidents (10%), falls (3%), accidents caused by falling objects (3%) and sport accidents (2%). The mandibular angle (n= 66, 43%) and the symphyseal area (n= 40, 26%) were the most common fracture sites. Combined fractures were found in 30% patients (26%). Of all angle fractures, 97% were related to third molars. One-hundred-and-five patients had open reduction by an intraoral approach and stabilization by 2.0 AO/ASIF titanium miniplates and nine closed reduction. Complications included temporary sensory deficit of the mental nerve (3%), minor malocclusion (2%) and infection or dehiscence (5%). We conclude that osteosynthesis of mandibular fractures by the 2.0 AO/ASIF titanium miniplate system is reliable.

Clinical applications of drill free screws in maxillofacial surgery

Drill free screws are newly designed osteosynthesis screws with specially formed tips and cutting flutes, which act like a cork-screw and can be inserted into bone without predrilling. A prospective study on 82 patients was performed in order to investigate the efficiency of mini- and micro-drill free screws (DFS) in clinical use and to find out areas in maxillofacial traumatology and orthognathic surgery, where the application of this new type of screw may be recommended. Thirty-eight Le-Fort-osteotomies, 23 central and lateral midfacial fractures and 21 fractures of the mandible were fixed using the Champy titanium micro/miniplate system and in total 518 center-drive titanium micro-DFS (1.5 mm) and 392 center-drive titanium mini-DFS (2 mm) with lengths between 4 and 7 mm. The results showed that the grip of micro- and mini-DFS was sufficient for the fixation of bone fragments in the central and lateral midface and in the mandibular area. The insertion of DFS was simple and is recommended in the area of the central midface; the insertion of the screws was difficult, but possible in the anterior mandible and in the lateral midface. The application of DFS in the mandibular angle region is not recommended.

Self-adapting washer system for lag screw fixation of mandibular fractures. Part II: In vitro mechanical characterization of 2.3 and 2.7 mm lag screw prototypes and in vivo removal torque after healing

The aim of this study was to mechanically characterize self-tapping 2.3 and 2.7 mm titanium lag screw prototypes which are part of the newly developed 'self-adapting washer' maxillofacial lag screw osteosynthesis system. In vitro in a screw testing machine the insertion torque, maximum locking torque and axial force and the ultimate torsional strength were assessed. In vivo in six miniature pigs using a mandibular symphyseal fracture model, the removal torques after 3 and 6 months of healing were measured. Additionally the bone-metal contact (BMC) of the screws was assessed histometrically. The maximum insertion torque (0.185 Nm) was far below the mechanical limits of the screws (2.3 mm = 0.96 Nm, 2.7 mm = 1.6 Nm). A tightening of the 2.7 mm screw with an axial force of 1000 N and of the 2.3 mm screw with 500-550 N leaves a safety margin of approximately one-third on the ultimate torsional strength. Clinically these values permit the use of two 2.3 mm lag screws or one 2.7 mm lag screw in mandibular symphysis fractures since 1000 N tensile axial force are required in this indication. During screw removal after 6 months healing, torque levels close to the mechanical limits of the screws were recorded and screw failures were observed. This failure rate may have been due to the BMC of 49.8% which was in the range of titanium dental implants. Accordingly the screw heads were reinforced to prevent fractures.

A computer study of fracture mobility and strain on biodegradable plates used for fixation of mandibular fractures

PURPOSE

This computer-based study was done to determine whether a small biodegradable plate system was suitable for internal fixation of mandibular fractures.

MATERIALS AND METHODS

In a three-dimensional computer model of the mandible, fracture mobility and plate strain were calculated for bite forces applied on 13 bite points on the dental arch. Simulated solitary angle, body, and symphysis fractures were fixed with one titanium miniplate, one polylactide (PLA) midiplate, one PLA maxiplate, or two PLA midiplates. Fractures with and without interfragmentary bone contact were studied. In the case of fractures with bone contact, the loads were transmitted through the fracture surfaces and the plate; when there was no contact, the loads were transmitted only through the plate. Maximum fracture mobility was set at 150 microm. Maximum plate strain was set at the yield strain of PLA and titanium.

RESULTS

For fractures without interfragmentary bone contact, all plate fixations resulted in a fracture mobility and plate strain higher than the limits set, except for the symphysis fracture fixed with two PLA midiplates. Interfragmentary bone contact significantly reduced fracture mobility and plate strain. For the angle fracture with bone contact, all PLA plate fixations resulted in a fracture mobility above the limit, whereas the titanium miniplate fixation had a fracture mobility below the limit. For the body and symphysis fracture with bone contact, only double PLA midiplate fixation resulted in a fracture mobility below the limit.

CONCLUSIONS

From a mechanical point of view, based on the computer model, small PLA plates are only suitable for symphysis fractures with and without interfragmentary bone contact and for body fractures with interfragmentary contact. However, fixation with two PLA plates is always necessary to provide sufficient reduction of fracture mobility and plate strain.

Prospective study on post-traumatic and postoperative sensory disturbances of the inferior alveolar nerve and infraorbital nerve in mandibular and midfacial fractures

In a prospective study (January 1999 to December 1997), 34 patients with 26 mandibular and 20 midfacial fractures were investigated. All the fractures were managed by osteosynthesis. To evaluate the incidence and duration of recovery of post-traumatic and postoperative sensory disturbances, the following tests were carried out: sharp/blunt testing, and the two-point discrimination test as conventional clinical examination methods, and electromyographic recording of the masseter reflex to calibrate the clinical findings. To establish the sensory status of the inferior alveolar and the infraorbital nerves in the region of the fracture, and on the intact and control sides, the tests were performed pre-operatively and postoperatively on the seventh day, after 4 weeks and after 3, 6 and 12 months. The incidence of post-traumatic sensory disturbance was 46% for mandibular fractures and 65% for fractures to the midface (sharp/blunt test, two-point discrimination test). The rate of postoperative sensory disturbance in surgical treatment of mandibular fracture involving the region of the intra bony course of the inferior alveolar nerve, including the post-traumatic sensory disturbance, was 76.9%, and 55% following surgical treatment of midfacial fractures. The incidence of persistent sensory disturbances following surgical treatment was 7.7% in the case of mandibular fractures, and 15% in the case of midfacial fractures (sharp/blunt test, two-point discrimination test, masseter reflex). Recovery of neurological function is delayed in the presence of a displaced fracture (> 1 mm) as compared with non-displaced fractures. For the postoperative calibration of sensory disturbances, electromyographic recording of the masseter reflex from the fourth postoperative week onwards has proved useful.

The self adapting washer for lag screw fixation of mandibular fractures: finite element analysis and preclinical evaluation

Besides rigid fixation, lag screws have distinct advantages compared with plates in appropriate indications in mandibular fractures. However, in current lag screw systems, the relatively small area of the screw head has to transfer the tensile force which can exceed 1000 N in the symphysis, to the thin cortical bone plate. Countersinking, which is obligatory in most systems, will weaken the cortical plate. Finite element analysis (FEA) revealed that load in this situation can exceed the normal tensile strength of metal and bone. Consequently, a new washer was constructed which both increased the supporting surface and did not require countersinking. The washer is self adapting (SAW) to the cortical plate in a defined position, forming a ball and socket joint with the screw head. Using the FEA model, a ten-fold reduction in load on bone and metal was observed with the new washer. In a miniature pig mandibular symphysis fracture model, the clinical applicability and a favourable histological reaction were demonstrated, compared with conventional lag screw designs.

Lag-screw fixation of anterior mandibular fractures using biodegradable polylactide screws: a preliminary report

PURPOSE

The purpose of this study was to evaluate the utility of biodegradable, self-reinforced poly-L-lactide screws (SR-PLLA) for lag-screw fixation of anterior mandibular fractures.

PATIENTS AND METHODS

SR-PLLA lag-screws were used to stabilize anterior mandibular fractures in 11 patients. Maxillomandibular fixation was used to treat concomitant mandibular condyle fractures for 2 weeks in four patients and for 1 and 5 weeks in two patients. Clinical and radiologic follow-up lasted for 6 months in 36% of patients and for 1 year in 64%.

RESULTS

Healing of all anterior fractures was uneventful, with no displacement or delay of bony union. No adverse reactions to the biodegradable screws were seen during follow-up.

CONCLUSION

Biodegradable SR-PLLA screw fixation seems to be a new and promising way of treating anterior mandibular fractures.

Etiology and incidence of maxillofacial fractures in the north of Jordan

OBJECTIVE

The objective of this investigation was to determine the causes and incidence of maxillofacial fractures in the country of Jordan.

DESIGN

A retrospective review of patient records and radiographs for the 5-year period from 1992 to 1997 was conducted. Data regarding age, gender, cause of fracture, anatomic site, and treatment modalities were reviewed.

RESULTS

During the 5-year period, 563 patients with 756 maxillofacial fractures were treated. The age range was 5 to 73 years (mean, 28.8 years). Of the 563 patients, 75.3% were male, with the peak incidence occurring in the age group 20 to 29 years. The bone of fracture was most frequently the mandible (seen in 419 cases, or 74.4% of the total), followed by the maxilla (76 cases; 13.5%), the zygomatic arch (60 cases; 10.7%), and the alveolar process (8 cases; 1.4%). Of the fractures, 55.2% were due to traffic accidents, 19.7% to accidental falls, and 16.9% to assaults. Most patients (82.3%) were treated by closed reduction surgery (45.2% with eyelet wiring; 54.8% with arch bars and intermaxillary fixation). Only 17.7% of patients were treated by open reduction surgery. All maxillary fractures were treated by orbital and circumzygomatic suspension with interdental wiring and intermaxillary fixation. Of the zygomatic complex fractures, 26 cases were treated with Gillies' temporal approach, 20 with percutaneous hook elevation, and 14 with observation alone.

CONCLUSION

The findings support the view that both the causes and the incidence of maxillofacial fractures vary from one country to another.

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.