Intermaxillary screw fixation in mandibular fracture repair

PURPOSE

To be successful, mandibular fracture reduction requires restoring premorbid occlusion. Intermaxillary fixation (IMF) is a founding principle of accurate mandibular fracture repair. Although arch bars are currently the standard in securing IMF, IMF screws have many potential benefits and should therefore not be overlooked. The goals of this study were to evaluate the effectiveness of IMF screws in the management of mandibular fractures, describe the technique, and identify those who will benefit from it without compromising the end results.

MATERIALS AND METHODS

Thirty-six consecutive patients with single or multiple displaced fractures of the mandible were treated using screw IMF. Open reduction internal fixation was then accomplished in the usual fashion. Postoperative plain films were used to evaluate fracture reduction and screw placement. Data were collected prospectively from clinical and radiologic evaluations at regular follow-up appointments.

RESULTS

Thirty-five (97.2%) of 36 patients demonstrated normal occlusion at the follow-up examination 6 weeks postoperatively. One case of root fracture and four cases of root impingement by screws were observed at the follow-up examinations.

CONCLUSIONS

Cortical bone screws offer a reliable alternative to more traditional methods of obtaining IMF in the treatment of mandibular fractures and present many advantages to the surgeon and the patient. Their use may be limited to specific clinical situations and potential consequences, of which the surgeon must be aware. Adequate preoperative planning is therefore essential to maximize successful results.

An analysis of etiological factors for traumatic mandibular osteomyelitis

OBJECTIVE

The aim of this study was to analyze the factors that were associated with the development of osteomyelitis during the treatment of mandibular fractures.

MATERIAL AND METHODS

The data of 3188 patients with mandibular fractures treated during 2002-2009 were analyzed. Traumatic osteomyelitis of the mandible was diagnosed in 207 patients. The background factors of complications were studied and compared with the control group (100 patients) not having complications after treatment of mandibular fractures. The data of clinical, roentgenologic, microbiological, and immunological investigations were analyzed. A logistic regression model was developed to identify the factors for osteomyelitis development.

RESULTS

The treatment in 6.5% of patients was complicated with osteomyelitis; 88.5% of these patients were men, and more than 80% of patients were younger than 50 years. In 86.8% of cases, Staphylococcus species were isolated, with Staphylococcus aureus accounting for 69.1% of cases. The following factors were found to be associated with osteomyelitis development: immunity dysfunction, caries-affected teeth at the fracture line, mobile fractured bones, bone fixation after more than 7 days following trauma, healthy teeth at the fracture line, insufficient bone reposition, and bone fixation after 3-7 days following trauma.

CONCLUSION

Comparative analysis of factors influencing the treatment results revealed a great importance of immunological and dental status and microflora at the affected site. Insufficient or late reposition and fixation of fractured bone fragments play a significant role in the healing process.

Improper reduction and fixation of bilateral anterior mandibular fractures: a case report

INTRODUCTION

Biomechanical principles for osteosynthesis are emphasized upon in oral and maxillofacial surgery residency programs.

DISCUSSION

Our case was referred from another specialty which had treated the patient for bilateral fractures of the anterior mandible. The gross malunion and other findings in this reported case serve to remind students and surgeons alike that principles of fracture reduction and fixation must be respected.

External fixation for mandible fractures

External fixation of mandible fractures is a useful technique when an open treatment is contraindicated because of extensive comminution, bone or soft tissue loss, and infection. This technique can also be used temporarily until definitive treatment is delivered. A uniphasic or biphasic system can be placed to reduce and stabilize mandibular fractures. These systems use surgically placed threaded pins and different types of connectors that can be manipulated to optimize the reduction of fractures. External fixation remains a quick, safe, and simple method to treat mandible fractures in selected clinical situations, and it should be part of the armamentarium in surgeons treating these injuries and fractures.

Mandibular stability after SSRO with or without postoperative maxillo-mandibular fixation for Class III malocclusion

OBJECTIVE

The objective of this study was to assess the usefulness of maxillo-mandibular fixation (MMF) from a viewpoint of skeletal and occlusal stability and to investigate the complications after surgery with and without MMF.

MATERIALS AND METHODS

Twenty-seven patients who underwent surgical correction of class III malocclusion were analyzed. The surgical procedure in all cases consisted of a bilateral sagittal splitting ramus osteotomy (SSRO). The segments were then fixed rigidly with titanium screws. A postoperative MMF was performed in 13 patients within 1 day of the SSRO. The MMF lasted for 1 week. The other 14 patients were free to move their jaw on the day of the surgery and received occlusal guidance with elastics starting from the third postoperative day. Cephalograms were taken preoperatively, at 1 day postoperatively and at 1, 3, 6, 12, and 24 months after surgery. Skeletal and occlusal stabilities along with postoperative complications were then assessed.

RESULTS

Discomfort of the pharynx and postoperative pain was more severe in the MMF group. Even without MMF, occlusion was guided to the ideal position by an average of 5.3 days after surgery. Occlusal and skeletal stability was satisfactory in both groups, and there was no correlation between the surgical results and postoperative MMF.

CONCLUSION

MMF may not be necessary after a rigid fixation SSRO, considering the risks of airway problems.

Do the benefits of rigid internal fixation of mandible fractures justify the added costs? Results from a randomized controlled trial

PURPOSE

Owing to its putative advantages over conventional maxillomandibular fixation (MMF), open-reduction and rigid internal fixation (ORIF) is used frequently to treat mandible fractures, particularly in noncompliant patients. The resource-intensive nature of ORIF, the large variation in its use, and the lack of systematic studies substantiating ORIF attributed benefits compel a randomized controlled investigation comparing ORIF to MMF treatment. The objective of this study was to determine whether ORIF provides better clinical and functional outcomes than MMF in noncomplying type of patients with a similar range of mandible fracture severity.

PATIENTS AND METHODS

From a total of 336 patients who sought treatment for mandible fractures, 142 patients with moderately severe mandible fractures were assigned randomly to receive MMF or ORIF and followed prospectively for 12 months. A variety of clinician and patient-reported measures were used to assess outcomes at the 1, 6, and 12 months follow-up visits. These measures included clinician-reported number of surgical complications, patient-reported number of complaints, as well as cumulative costs of treatment. Pain intensity was measured on a 10-point scale and the 12-item General Oral Health Assessment Index was used to assess the patients' oral health-related quality of life. Because the protocol allowed clinical judgment to overrule the randomly assigned treatment, outcomes were compared on an "intent-to-treat" basis as well as in terms of actual treatment received.

RESULTS

The sociodemographic and clinical characteristics of the injury did not differ among the 2 groups. On an intent-to-treat basis, the difference in complication rates was not significant but favored MMF; 8.1% of patients developed complications with MMF versus 12.5% with ORIF. Differences in the rate of patient complaints were not significant on an intent-to-treat basis, but a significant between-group difference (P = .012) favoring MMF was noted on an as-treated basis at the 1 month recall, with 40% of ORIF patients reporting greater than 1 complaint versus 18.8% of MMF patients. No significant differences were detected between the 2 treatment groups at any time point with respect to oral health-related quality of life reflected by the General Oral Health Assessment Index scores. In-patient days and total costs did not differ significantly on an intent-to-treat basis, but on an as-treated basis, patients treated with MMF had fewer in-patient days on average (1.64 vs 5.50 for ORIF) and lower average costs of treatment ($7,206 vs $26,089 for ORIF). In the intent-to-treat analyses, patients receiving MMF treatment had significantly lower (P = .05) pain scores at the 12-month recall (mean = 0.58, SE = 0.30) compared with patients assigned to ORIF (mean = 1.78, SE = 0.52).

CONCLUSION

Our study did not show a clear overall benefit of the resource-intensive ORIF over conventional MMF treatment in the management of moderately severe mandible fractures in at-risk patients; our data instead suggest some cost as well as oral health quality-of-life advantages for the use of MMF in this patient population.

Allergy to metal caused by materials used for intermaxillary fixation: Case report

A 21-year-old man with no history of contact allergy developed eczema over his entire body 2 days after he had had intermaxillary fixation (IMF) of a mandibular fracture. Patch testing showed a strong reaction to nickel so the arch bars and wires that had been used for fixation were removed and replaced with resin brackets, elastic bands, and a chin cap. The eczema disappeared 2 days later.

Use of straight and curved 3-dimensional titanium miniplates for fracture fixation at the mandibular angle

PURPOSE

The aim of this follow-up study was to evaluate the clinical usefulness of a new type of 3-dimensional (3D) miniplate for open reduction and monocortical fixation of mandibular angle fractures.

PATIENTS AND METHODS

In 20 consecutive patients, noncomminuted mandibular angle fractures were treated with open reduction and fixation using a 2 mm 3D miniplate system in a transoral approach. All patients were systematically monitored until 6 months postoperatively. Among the outcome parameters recorded were infection, hardware failure, wound dehiscence, and sensory disturbance of the inferior alveolar nerve.

RESULTS

The mean operation time from incision to wound closure was 65 minutes. Two patients had a mucosal wound dehiscence with no consequences. None developed an infection requiring a plate removal. All but 2 patients had normal sensory function 3 months after surgery. Plate fracture occurred in one patient in whom a preceding surgical removal of the third molar had been the reason for the mandibular fracture. In the absence of clinical symptoms, the patient declined plate removal. On final follow-up, fracture healing was considered clinically complete in all patients.

CONCLUSIONS

The 3D plating system described here is suitable for fixation of simple mandibular angle fractures and is an easy-to-use alternative to conventional miniplates. The system may be contraindicated in patients in whom insufficient interfragmentary bone contact causes minor stability of the fracture.

Application of Intermaxillary Fixation Screws in Maxillofacial Trauma

PURPOSE

The use of intermaxillary fixation (IMF) in the treatment of maxillofacial trauma represents the cornerstone of fracture reduction and immobilization. Many modalities of IMF have been described; recently IMF screws have been introduced into clinical practice, however, hardware failure can occur. We performed a retrospective study evaluating hardware-associated complications for self-drilling/tapping IMF screws.

MATERIALS AND METHODS

A retrospective study on 49 patients requiring IMF was performed. The diagnosis, duration of IMF, screw site, use of elastic or wire fixation, and associated complications were recorded. IMF screws were used to adjunct open reduction techniques, for definitive closed reduction, or fracture prevention following dentoalveolar surgery. Follow-up examinations were performed until fracture healing was complete (6 to 8 weeks).

RESULTS

A single adverse event occurred in 19 patients (39%) while 4 patients (8%) had more than 1 complication. The most common event was screw loosening; 29% of patients had at least 1 screw dislodged in the treatment period. Of the total number of screws placed (229), 15 (6.5%) became loose, and were equally distributed among the mandible and maxilla. The remaining complications noted were root fracture, 4% (2 of 49); loosened wires, 6% (3 of 49); screw shear, 2% (1 of 49); malocclusion, 2% (1 of 49); and ingested hardware, 2% (1 of 49).

CONCLUSIONS

Overall the IMF self-drilling/tapping screws have been shown to be a useful modality to establish maxillomandibular fixation. It is a safe, and time-sparing technique; however, it is not without limitations or potential consequences which the surgeon must be aware of in order to provide safe and effective treatment.

A comparison of lower lip hypoesthesia measured by trigeminal somatosensory-evoked potential between different types of mandibular osteotomies and fixation

PURPOSE

The purpose of this study was to compare objectively, the recovery of hypoestheia of the lower lip following orthognathic surgery using different procedures (sagittal split ramus osteotomy [SSRO]) and intra-oral vertical ramus osteotomy (IVRO)) and fixation methods (monocortical plate fixation and bi-cortical plate fixation). Hypoesthesia was evaluated using the trigeminal somatosensory-evoked potential (TSEP).

PATIENTS AND METHODS

The subjects consisted of 174 patients (348 sides) with mandibular prognathism with or without asymmetry, who underwent mandibular ramus osteotomies using different fixation types. The patients were divided into 4 groups. The OAM group consisted of 128 sides who had SSRO using the Obwegeser method with mono-cortical absorbable plate fixation, the ODTM group consisted of 84 sides who had the Obwegeser-Dal Pont method with mono-cortical titanium plate fixation, the OTB group consisted of 32 sides who had the Obwegeser method with bi-cortical titanium plate fixation and the VO group consisted of 104 sides who underwent IVRO according to the Bell method without fixation. Trigeminal nerve hypoestheia at the region of the lower lip was assessed bilaterally by the TSEP method. An electroencephalograph recording system (Neuropack Sigma; Nion Koden Corp., Tokyo, Japan) was used to analyze the potentials. Each patient was evaluated pre-operatively and then post-operatively at 1 and 2 weeks, 1, 3, and 6 months, and 1 year.

RESULTS

The mean measurable period and standard deviation of TSEP of the lower lip in the OAM group was 5.2 +/- 9.9 weeks, 10.9 +/- 13.1 weeks in the ODTM group, 7.8 +/- 4.5 weeks in the OTB group, and 2.5 +/- 6.3 weeks in the VO group. There were significant differences between the OAM and ODTM groups (P < .0001), the ODTM and OTB groups (P = .0001), the OTB and VO groups (P = .0221), the OAM and VO groups (P < .0001), and the ODTM and VO groups (P < .0001).

CONCLUSION

This study proved using objective measurements that the recovery period from hypoesthesia of the lower lip following orthognathic surgery was dependent on the surgical procedure. Recovery in lower lip hypoesthesia after IVRO was significantly earlier than SSRO.

Decision-Making Process for Treatment of Mandibular Fractures among Minority Groups

OBJECTIVES

While patients' preferences for medical care are widely studied, only a small number of studies have looked at the decision-making process for dental treatment of mandibular fracture. This study examines the decision-making process for treatment of mandibular fractures among minority groups. Study participants were asked to consider Maxillomandibular Fixation (MMF--a non-surgical approach of wiring the teeth for 4-8 weeks) or Rigid Internal Fixation (RIF--surgical placement of bone plate).

METHODS

A qualitative study of patients receiving care at an inner-city hospital for either 3rd molar extraction under general anesthesia or a mandibular fracture were recruited to participate in an hour-long focus group to discuss their preferences. The 3rd molar group was selected as a comparison group exemplifying experience with oral surgery and recovery from general anesthesia.

RESULTS

Seven decision-making factors affecting choice of treatment were discussed by both jaw fracture and 3rd molar groups, including: side effects, effectiveness of each treatment, trusting doctor's recommendation, what to expect from each procedure, use of pictures from previous case studies, surgery location of scar/incision, and size of scar. Rigid Internal Fixation (RIF) participants discussed a different set of concerns compared to Maxillomandibular Fixation (MMF) participants.

CONCLUSIONS

Regardless of gender, the treatment of choice for both 3rd molar and jaw fracture participants was the non-surgical method of wiring of the teeth for 4-8 weeks. The Phase II part of this study will systematically examine patient preferences among a larger sample of 3rd molar and jaw fracture patients by incorporating the patient-reported concerns about treatment of jaw fracture found in this inductive, phenomenological study.

Etiology and management of posttraumatic malocclusions

AIM

To establish the etiology of complications in patients undergoing treatment of maxillofacial trauma and justify the treatment of choice.

METHODS

Four patients with posttraumatic occlusal irregularities comprised the subjects.

RESULTS

Posttraumatic malocclusion has a complex etiology. The evaluation of the pretraumatic occlusal relationship is useful but not always possible. Anatomic repositioning of the fracture should be performed as soon as possible. Patients whose fractures are treated via maxillomandibular fixation who do not receive surgical reduction of a posttraumatic fracture have a greater possibility of later developing more severe dental and skeletal malocclusions. In cases treated via maxillomandibular fixation, Ivy loops should be avoided.

CONCLUSION

When treating patients with maxillofacial trauma, care should be taken to counterbalance possible obstacles. This will result in a satisfactory posttraumatic occlusal scheme, without the need for orthodontic treatment or a second surgery.

Mandibular fractures treated with maxillomandibular fixation screws (MMFS method)

The purpose of the treatment of mandibular fractures is to restore proper dental occlusion and stable temporomandibular joint movement, as well as the reduction of the displaced fracture. Consideration must be given to the selection of the most appropriate surgical and rehabilitation methods in such patients. Typical surgical methods for the treatment of mandibular fractures include the arch bar method or plating at the location of the fracture combined with fixing the mandible to the maxilla using the arch bar method. However arch bars and circumdental wires, which require teeth for fixation, damage teeth and periodontal tissue, and tend to be uncomfortable for patients during the fixation period. Moreover, daily maintenance of oral hygiene is difficult for patients with an arch bar. Surgeons are also exposed to the risk of blood-transmitted diseases through skin punctures by wires when affixing these devices. For these reasons, we chose to study the potential of the MMFS method, which is thought to lessen all of the following problems: tissue damage, operating time, patient discomfort, and possible exposure to percutaneous infectious disease due to puncture of gloves and skin by the wires. We demonstrated the utility of the MMFS method in the present study.

Neurosensory Alteration in the Lower Lip and Chin Area After Orthognathic Surgery: Bilateral Sagittal Split Osteotomy Versus Inverted L Ramus Osteotomy

PURPOSE

This study investigated neurosensory disturbances in patients after orthognathic surgery in relation to differences in mandibular splitting methods and degree of surgical skill.

PATIENTS AND METHODS

Forty-five patients who had undergone bilateral sagittal split ramus osteotomies (SSRO), and 21 (group L) who had undergone intraoral inverted L ramus osteotomies (ILRO), were examined for postsurgical neurosensory disturbances. Twenty-two (group S1) of the SSRO patients were treated by 11 surgeons who had little experience, and the others (23 patients; group S2) were treated by 2 skilled surgeons who had considerable experience. One of the 2 skilled surgeons was the only surgeon carrying out the ILRO procedure. The neurosensory tests employed included light touching using a Semmes-Weinstein monofilament tester (SW tester), electrical stimulation, and a questionnaire to determine changes in subjective sensations, at the time of each sensory evaluation. Neurosensory examinations were carried out bilaterally (132 sides) at 1, 3, 6, and 12 months after surgery.

RESULTS

More patients showed abnormal thresholds for the 2 measurement techniques in the SSRO group than in the ILRO group, and furthermore there were more such patients in group S1 than in group S2, at each measurement point. At 6 months after surgery, the number of patients with reduced sensitivity was significantly higher in group S1 than in group L (P < .05). In the SSRO group at each measurement point, the thresholds for the lower lip and chin were unrelated to the set-back (or advance) distance. By contrast, in group L only at the 1-month evaluation point, the thresholds for the lower lip and chin were significantly raised in patients whose setback distances were larger than average (P < .05).

CONCLUSIONS

Postsurgical neurosensory disturbances of the lower lip and chin occur more frequently in SSRO patients treated by surgeons having little experience than in those treated by skilled surgeons, although the difference is not significant. Long-term prognosis for resolution of postsurgical neurosensory disturbances is better in ILRO patients than in SSRO patients. Although the width of movement of the split bone fragments has an influence on postsurgical neurosensory disturbances immediately after ILRO, the relationship becomes less obvious with time.

Management of the perforations due to miniplate application

Microdimensioned osteosynthesis using miniplates has been common practice in maxillofacial surgery. However, tooth injury during the application of the miniplates have been reported in few papers. In this case, a 32-yr-old female patient, whose two teeth were necrosed because of the perforation during screw insertion was presented. The reason of the perforations during the rigid internal fixation was the lack of radiographic assessment because of the pregnancy. Maxillary right first premolar and maxillary left canine were perforated and necrosed because of the screw insertion. The necrosed teeth were detected 1 yr after the rigid internal fixation. The root canals of nonvital teeth were filed using step-down approach. Cold lateral condensation of gutta-percha was used to fill the canals. Six-month recall visits were scheduled and there was no problem after 2-yr follow-up period.

The Incidence of Postoperative Wound Healing Problems Following Sagittal Ramus Osteotomies Stabilized With Miniplates and Monocortical Screws

PURPOSE

Titanium plates and monocortical screws are commonly used to stabilize the mandible following sagittal split ramus osteotomies. Despite widespread use of this type of fixation, there is a paucity of large studies evaluating the infection rate and need for hardware removal.

MATERIALS AND METHODS

This study is a retrospective cohort evaluation of 1,066 consecutive mandibular sagittal ramus osteotomies in 533 patients, performed between January 2002 and December 2003. All osteotomies were stabilized with 4-hole miniplates and 2.0 mm x 5.0 mm monocortical screws. Study variables included disturbances of wound healing, age, gender, plate and screw position, direction of mandibular movement, adjunctive procedures performed, and the patient's medical history. Data were collected by chart and radiographic review. The above variables were analyzed using Fisher's exact test, Chi-square, Cochran-Armitage Trend Test, and multiple logistic regression.

RESULTS

Of 533 patients 26% (138) demonstrated wound healing problems. This occurred in 15% of all 1,066 osteotomy sites. 6.5% of plates required removal in 10% of patients. In no case did disturbance of wound healing or plate removal result in non-union or relapse of the osteotomy. Wound healing problems were fewer when mandibular osteotomies were done in conjunction with maxillary surgery (18.9% versus 29.1%). Disturbances of wound healing were not related to the direction of movement of the mandible and were lower when hardware was placed closer to the inferior border.

CONCLUSION

An overall low incidence (6.5%) of hardware infection requiring plate removal was found in this study. Screw proximity to the osteotomy site did not correlate with higher rates of healing problems, but there was a statistically significant trend of fewer disturbances of healing when the hardware was placed closer to the inferior border of the mandible.

Contributing factors to mandibulotomy complications: A retrospective study

OBJECTIVE

The purpose of this article is to investigate the complications associated with mandibulotomies and analyze contributing factors.

STUDY DESIGN

A total of 103 patients, who had undergone a mandibulotomy for tumors of the oral cavity or oropharynx, were identified and their hospital records, clinical charts, and radiographs retrospectively reviewed. Variables associated with mandibulotomy complications (osteotomy type, osteotomy site, tooth extraction, fixation method, radiation, and chemotherapy) were classified and statistically analyzed.

RESULTS

Various complications were encountered in 19 (18.4%) patients, and were classified into 2 categories: intraoperative and postoperative complications. Paramedian (42.7%) stair-step (86.4%) osteotomies had been frequently used. Rigid fixation using one monocortical plate, one bicortical plate, and screws (MCP + BCP [46.6%]) was the main fixation method and showed statistical significance in the complications of mandibulotomy (P < .05). Five (71.4%) out of 7 patients who received preoperative radiotherapy developed postoperative complications, and 3 (60%) out of 5 patients who received preoperative chemotherapy developed complications. Among the complications, nonunion was observed in 7 (6.7%) patients and osteoradionecrosis in 5 (4.9%).

CONCLUSION

Paramedian stair-step osteotomy is recommended and the reapproximation is improved with minimal bone loss using a thin saw blade. Rigid monocortical and bicortical plate fixation (MCP + BCP) is advantageous to preventing postoperative complications. Perioperative radiation therapy contributes to those complications, therefore it is necessary to establish the precise position of the portals and the adequate dose of radiotherapy through consultation with a radiation oncologist preoperatively, and consider a proper surgical approach. Because infection is an important contributing factor, it is necessary to actively control the infection to decrease the incidence of complications.

Perceived effectiveness and side effects of intermaxillary fixation for diet control

Weight loss is one of the major side effects associated with intermaxillary fixation (IMF) following orthognathic surgery or jaw fractures. The aim of this study was to retrospectively interview patients treated with intermaxillary fixation for diet control (IMFDC) to collect base-line information regarding: (1) perceived effectiveness, patients' compliance and patients' satisfaction with the treatment; (2) the frequency of side effects associated with IMFDC. The results show that IMFDC significantly reduced weight by a mean of 6.8 kg during treatment, and a mean of 4.1 kg at a minimum of 1 month following IMFDC removal (P<0.0001). Only 32.5% of the patients complied with the planned period of IMFDC treatment while 70% were satisfied with the treatment results. The most common side effects were speech problems and oral-facial pain with a prevalence of 52.5 and 32.5%, respectively. IMFDC treatment is not effective for long-term weight reduction and may only be used for a very short period of time to initiate weight loss. Exercise and/or special diet programs are healthier and better means to treat obesity and maintain weight loss.

Current therapy: complications associated with rigid internal fixation of facial fractures

Rigid internal fixation (RIF) is commonly used for the anatomical reduction and fixation of facial fractures. This technique has many advantages over more traditional methods, such as wire osteosynthesis and maxillomandibular fixation. Properly placed RIF ensures a stable anatomical reduction and allows for immediate or early restoration of function. RIF has a number of complications associated with its use in facial trauma surgery including metal sensitivity, infection, neurologic injury, dental trauma, stress shielding, and malocclusion. Complication rates appear to be inversely proportional with operator skill and experience when using RIF.

Fixation of mandibular angle fractures with a 2.0-mm 3-dimensional curved angle strut plate

PURPOSE

The aim of this study was to evaluate our experience and complication rate with the use of a 3-dimensional 2.0-mm curved angle strut plate for mandibular angle fracture fixation.

PATIENTS AND METHODS

This was a retrospective evaluation of 37 patients with noncomminuted mandibular angle fractures fixated with a transorally placed curved 2.0-mm strut plate. Postoperative intermaxillary fixation was used in 5 patients for a mean period of 22 days. A nonchewing diet was prescribed for 6 weeks. Records were reviewed for demographic information, medical history, fracture characteristics, operative management, and complications.

RESULTS

Two patients developed infections requiring plate removal and reapplication of fixation. Both of these patients had a molar in the fracture line that was left in place during the first operation. One patient developed a mucosal wound dehiscence without consequence. After a mean follow-up period of 10 weeks, 39.4% of patients with a postinjury/pretreatment inferior alveolar nerve deficit reported a return to normal sensation. All patients who developed a sensory deficit as a result of surgery reported full recovery of sensation. A persistent sensory deficit appeared to be related to fracture displacement.

CONCLUSION

Fixation of noncomminuted mandibular angle fractures with a 2.0-mm curved angle strut plate was predictable. This plate is low in profile, strong yet malleable, facilitating reduction and stabilization at both the superior and inferior borders. Development of a postoperative infection appeared to be related to failure of removal of a molar in the fracture line. The infection rate of 5.4% found in this study compares favorably with that seen with reconstruction plates. Use of this plate did not appear to cause a permanent sensory deficit in this study.

Sagittal split osteotomy of a vascularised iliac crest free flap to correct residual asymmetry and malocclusion in the reconstructed mandible

Reconstruction of the mandible with a vascularised bone graft from the iliac crest based on the deep circumflex iliac artery is an established and reliable technique. We report two cases in which mandibular asymmetry followed reconstruction with such grafts and was corrected by sagittal split osteotomies.

Complications of Bicortical Screw Fixation Observed in 482 Mandibular Sagittal Osteotomies

Bicortical screw fixation after bilateral sagittal split osteotomy (BSSO) of the mandible is commonly used in orthognathic surgery and allows many advantages compared with osteosynthesis wires and maxillomandibular fixation. Complications include early loosening, hardware exposition, skeletal instability or early relapses, persistent nerve impairments, infection, and scar formation. This article is based on a retrospective analysis of complications of bicortical screw fixation observed in 241 consecutive patients with dento-skeletal Class III, corresponding to 482 sides, during the immediate postoperative period and at 1, 3, 6, and 12 months' follow-up. In the immediate postoperative period, poor stability of fixation caused by screw loosening was observed in 3 of 482 (0.62%) sides; at the 1-month follow-up, infections were encountered in 12 (2.48%) sides at mandibular angles. Additional complications were not seen in the series. Stability of fixation was found in the 482 sides at 12 months. However, complications directly related to bicortical screws were observed in 15 sides or 3.11%. Age and gender of patients were not correlated with the incidence of complications. Assiduous follow-up during the early postoperative period and 1 and 2 months after surgery is recommended in patients with bicortical screw fixation after BSSO to verify adequate oral hygiene and provide early observation of the onset of any infections, skeletal instabilities, or relapses.

Frey's syndrome after condylar fracture: case report

Frey's syndrome is the occurrence of hyperesthesia, flushing and warmth or sweating over the distribution of the auriculotemporal nerve and/or greater auricular nerve while eating foods that produce a strong salivary stimulus. Frey's syndrome is also known as auriculotemporal syndrome and gustatory sweating. We present a case of Frey's syndrome after a condylar fracture and its treatment by internal rigid fixation. A review of the literature is provided along with mention of a simple test (Minor's test) that can help in the diagnosis of this syndrome.

Therapeutic effect of TENS on post-IMF trismus and pain

The study set out to investigate the therapeutic effect of Transcutaneous Electrical Nerve Stimulation (TENS) in the alleviation of pain and post-IMF trismus, in patients undergoing jaw exercises to hasten mouth opening after being treated for fractures of the mandible. Two groups of patients, with 10 patients in each group, were used for the study. The groups were the experimental and the control groups. They were all treated for mandibular fractures, and had their jaws immobilized for 6 weeks, immediately after which they were started on jaw exercises. The Inter-incisal distances and number of acceptable wooden spatulae that the jaws could accommodate were noted and recorded. The experimental group was then placed on the TENS therapy for 20 minutes, after which the new inter-incisal distances and the number of acceptable wooden spatulae were recorded. The control group had no TENS therapy; the patients only waited for 20 minutes without any stimulation, before the new inter-incisal distances and the number of acceptable wooden spatulae were measured and recorded. It was observed that the inter-incisal distance and the number of acceptable wooden spatulae significantly increased in patients in the experimental group compared to the control group. It was concluded that TENS could be useful in relieving the pain associated with forced mouth-opening exercises aimed at overcoming trismus caused by muscle spasm, which is associated with prolonged immobilization of the jaws for the treatment of facial fractures.

Comparative assessment of two methods used for interdental immobilization

AIM

This investigation was carried out to compare Dimac wires with arch bars for interdental immobilization.

MATERIAL AND METHODS

The assessment was conducted on 50 patients who had mandibular fractures and in whom intermaxillary fixation was required as a part of the treatment. The time required for applying each method of fixation, the needle-stick injuries that occurred during their application, and the periodontal damage that followed interdental immobilization was investigated.

RESULTS

The mean time required for the application of Dimac wires was significantly less than that required for arch bars. The needle-stick injuries were significantly less with Dimac wires. Patients reported difficulty with oral hygiene with arch bars in place. This was associated with periodontal damage following removal of fixation.

CONCLUSION

Dimac wires is safer to use and less traumatic to the periodontium

Retromandibular approach to the mandibular condyle: a clinical and cadaveric study

This prospective study was carried out to assess the morbidity of the retromandibular approach in the management of condylar fractures. Twenty consecutive patients underwent open reduction and internal fixation of their condylar fractures using this technique. Branches of the facial nerve were encountered in six cases (30%). Temporary weakness of the facial nerve occurred in six patients (30%), but this resolved in all cases within 3 months and there were no cases of permanent nerve injury. Two patients had a temporary deficit of the great auricular nerve and one patient developed a sialocoele that resolved with aspiration. A cadaveric study using 30 facial halves (15 fresh cadavers) was also conducted. Branches of the facial nerve were encountered in 12 dissections (40%). The literature regarding facial nerve morbidity in relation to the management of condylar fractures is reviewed.

Infections associated with locking reconstruction plates: a retrospective review

PURPOSE

In this study, we examined the incidence of infection with the use of a locking reconstruction bone plate/system.

PATIENTS AND METHODS

All patients, treated with a locking reconstruction bone plate/screw system for mandible fractures in the Oral and Maxillofacial Surgery service over a 28-month period at a level I trauma center, were evaluated through a retrospective chart review by independent examiners. The use of a locking reconstruction plate was determined by the attending staff involved in the patient's care. Patient population included single, bilateral, and comminuted fractures. Patient characteristics were noted and include dentate versus edentulous, smoking history, and history of previous infection.

RESULTS

Fifty-six locking bone plates were placed in 42 patients. Eight (19%) of the patients were infected before treatment. A persistent infection remained in 3 of these 8 patients (37.5%). Two patients (5.8%), with 3 fracture sites (6.4%) developed postoperative infection that required further intervention. All 5 of the patients who were infected after surgery were heavy smokers. History of preoperative infection and smoking appear to be significant factors in the etiology of postoperative infection. All postoperative infections resolved successfully with local measures and with no loss of fixation.

CONCLUSION

The use of locking reconstruction plates can facilitate the management of complicated fractures; however, it does not eliminate complications. Postoperative infections are related to numerous factors, including preoperative incidence of infection, smoking, and proper use of the plates.

Treatment of severe mandibular fractures using AO reconstruction plates

PURPOSE

The goal of this study was to retrospectively evaluate the use of 2.4-mm AO titanium reconstruction plates for mandibular fractures.

PATIENTS AND METHODS

We analyzed the clinical and radiologic data of 63 patients with 63 single fractures (53 comminuted, 5 dislocated, and 5 with bone loss) and 2 patients with double fractures. Fracture location was symphysis in 37 patients (56.9%), body in 13 (20%), and angle in 15 (23.1%). We recorded the mechanism of injury, time between injury and surgery, gender and age, temporary maxillomandibular fixation (MMF) and its duration, and surgical approach. Follow-up examinations were performed at 1, 3, 6, and 12 months, at which time we noted the status of healing and any complications.

RESULTS

Fifty patients (77%) had a successful treatment outcome without complications; 13 patients (20%) developed minor complications; and 2 patients (3%) developed nonunion with infection requiring hardware removal and reosteosynthesis with bone graft.

CONCLUSIONS

We found that 2.4-mm AO titanium reconstruction plates can be used to treat severe mandibular fractures with a low rate of major complications (3%) and a high success 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.

Effect of maxillomandibular fixation on the incidence of postoperative pulmonary atelectasis

PURPOSE

Our goal was to assess the role of maxillomandibular fixation (MMF) on postoperative atelectasis.

PATIENTS AND METHODS

We examined 64 patients in 2 groups: MMF and non-MMF. Atelectasis was diagnosed by comparing preoperative and postoperative chest radiographs, arterial blood gas analysis, and axial temperatures. Postoperative chest computed tomography scans were also used as the best way to detect atelectasis.

RESULTS

Of the MMF and non-MMF patients, 37.5% and 15.6%, respectively, sustained atelectasis (P <.05). Plate type was the most prevalent (71%). The right lung was more involved (59%). Fever was not a significant finding in atelectatic patients (P >.10). PaO(2) was decreased in some cases of atelectasis, especially in patients with extensive involvement.

CONCLUSION

MMF should be considered as a contributing factor for postoperative pulmonary atelectasis.

Effects of age, amount of advancement, and genioplasty on neurosensory disturbance after a bilateral sagittal split osteotomy

PURPOSE

There are numerous risks for developing neurosensory deficits after a bilateral sagittal split osteotomy (BSSO). The purpose of this study was to evaluate the effects of genioplasty, length of advancement, and age and their interactions in a group of patients undergoing BSSO advancement and followed up for 2 years.

MATERIALS AND METHODS

Patients were examined at multiple time intervals during the 2 years. Measuring in the mental nerve distribution assessed damage. 127 subjects were divided into the following 3 age groups: younger than 24 years, 24 to 35 years, and older than 35 years old. They also were divided into small (< or =7 mm) and large (>7 mm) advancements and genioplasty and no genioplasty. Change in tactile sensitivity from presurgical to the subsequent time periods is reported as a function of these variable and interactions among the variables. Data were analyzed using the Kruskal-Wallis test and the Friedman test, all at an alpha level of 0.05.

RESULTS

Older subjects had greater sensory losses than younger subjects. Patients with a genioplasty had a greater loss of sensation initially. For all subjects, the sensory function of those receiving large and small advancements was not significantly different. Among subjects receiving small advancements there was no significant difference among the 3 age groups. However, among patients receiving advancements greater than 7 mm, older patients did worse. Among patients not receiving genioplasty, there was no significant difference among the 3 age groups. In contrast, older subjects with a genioplasty had significantly greater sensory deficits.

CONCLUSIONS

Age at the time of surgery and addition of a genioplasty increases the risk of a neurosensory injury. Large advancements further increase the risk of injury in older patients.

Treatment methods for fractures of the mandibular angle

Fractures of the mandibular angle are plagued with the highest rate of complication of all mandibular fractures. Over the past 8 years, the following six accepted forms of treatment for these fractures were performed on an indigent inner-city population: closed reduction or intra-oral open reduction and nonrigid fixation; extraoral open reduction and internal fixation with an AO/ASIF reconstruction bone plate; and intraoral open reduction and internal fixation using either two 2.0 mm minidynamic compression plates, two 2.4 mm mandibular dynamic compression plates, two noncompression miniplates, or a single noncompression miniplate. This article reviews the results of those treatment modalities when used for the same patient population at one hospital. Results show that the use of either an extraoral open reduction and internal fixation with the AO/ASIF reconstruction plate or intraoral open reduction and internal fixation using a single miniplate was associated with the fewest complications.

Transverse displacement of the proximal segment after bilateral sagittal osteotomy

PURPOSE

The aim of the present investigation was to evaluate the transverse displacement of the proximal segment and ramus rotation after a bilateral sagittal osteotomy (BSO) with rigid internal fixation (RIF) using bicortical LAG screws.

PATIENTS AND METHODS

We conducted a retrospective review of 37 patients (14 males and 23 females, age range of 14 to 55 years) who underwent a mandibular advancement with BSO and RIF. Posteroanterior and lateral cephalometric radiographs were obtained 1 to 8 weeks before and 1 to 4 weeks after surgery. The transverse displacement and angulation of the proximal segments after surgery were measured on posteroanterior radiographs, using the best-fit method. The amount of mandibular advancement was compared with the amount of transverse displacement of the proximal segments.

RESULTS

In the 1 to 4-week postoperative period after a BSO, 36 of 37 subjects showed an increased transverse intergonion distance (5.6 mm) (P <.0001) and 35 of 37 patients showed an increased transverse interramus width (3.3 mm) (P <.0001). No correlation was found between mandibular advancement and transverse displacement of the proximal segment.

CONCLUSIONS

The study results indicate that transverse displacements of the proximal segments occur with BSO and RIF. The clinical impact on temporomandibular joint symptomatology or surgical relapse with such displacement was not assessed in the study. Future studies that address these issues may help to determine whether there is an association between proximal segment displacement and surgical relapse, temporomandibular dysfunction, or both.

Incidence of complications and problems related to orthognathic surgery: a review of 655 patients

PURPOSE

This retrospective report evaluates the incidence of pre-, intra-, and postoperative complications of orthognathic surgery and their significance to the patient.

PATIENTS AND METHODS

The clinical records and radiographs of 655 patients operated on in Vaasa Central Hospital, Finland during a 13-year period between 1983 and 1996 were examined. The total number of operations was 689. All notes referring to problems or complications from the orthodontic phase to the varying postoperative follow-up times were gathered and analyzed.

RESULTS

The most common complication was a neurosensory deficit in the region innervated by the inferior alveolar nerve; mild in 32% of patients (183 of 574 patients with an osteotomy in the mandible) and disturbing in 3% of patients (18/574). The most serious complication was severe intraoperative bleeding in 1 patient necessitating major blood transfusions and later embolization of the internal maxillary artery. There were no fatal complications. The incidence of other problems was low, and there were very few patient complaints.

CONCLUSIONS

Despite the great variety of severe complications reported in the literature, their frequency seems to be extremely low, and orthognathic surgery treatment can be considered to be a safe procedure.

Plate fixation of extra-oral subcondylar ramus osteotomy for correction of mandibular prognathism: clinical aspects and short term stability

AIM

The present study describes an extra-oral approach for subcondylar oblique ramus osteotomy using stable fixation for setback of the mandible. The aim was to investigate the incidence of neurosensory disturbances of the mandibular nerve, evaluate facial scar appearance, and assess skeletal stability following the procedure.

METHODS

Forty-two consecutive patients with mandibular prognathism were operated upon using the subcondylar oblique ramus osteotomy and plate fixation. The patients were followed up for 6 months following surgery. Intra-operative and postoperative complications, neurosensory function, and facial scar characteristics were recorded. Lateral cephalograms were available immediately before operation, and immediately after operation and 6 months postoperatively. Skeletal stability was based on cephalometric assessment.

RESULTS

Among the 19 patients operated earliest, neurosensory disturbances were recorded in five individuals at the 6 month follow-up. In the subsequent group of 23 patients, no disturbances were reported. All but two patients were not concerned about the facial scar 6 months postoperatively. Mean anterior relapse at the 6 month follow-up was 0.5 mm, representing 9% of the surgical setback.

CONCLUSION

Extra-oral subcondylar oblique ramus osteotomy with plate fixation is a stable procedure with a low incidence of neurosensory disturbances if the osteotomy is placed well behind the mandibular foramen. Facial scar appearance was rarely a matter of concern to the patients.

Effect of partial immobilization on reconstruction of ankylosis of the temporomandibular joint with an autogenous costochondral graft:an experimental study in sheep

The purpose of this study was to show the effect of partial immobilization of a costochondral graft reconstruction of an ankylosed temporomandibular joint (TMJ) in five adult sheep. Ankylosis was induced in all right TMJs. At three months, a graft was inserted and partially immobilized. Three months after the second operation, four sheep were killed by an overdose with pentothal. One sheep was killed at one month because of infection. Functionally, the body weight, which decreases with ankylosis, did not recover after insertion of the graft and the range of jaw movements got worse. Histologically, the grafts were well attached to the mandibular rami in three of four joints. In one joint, the graft showed signs of resorption and a foreign body reaction. We conclude that, if the reconstructed joint is partially immobilized, then there will be a degree of reankylosis. There was also a high failure rate.

Effects of intermaxillary fixation during orthognathic surgery on respiratory function after general anesthesia

I examined the relationship between preoperative breathing route (nasal and/or oral) and respiratory status in 29 patients who underwent orthognathic surgery and intermaxillary fixation (IMF) with general anesthesia and in 14 healthy, adult control volunteers who received IMF without surgery or anesthesia. The tidal volume (VT), minute respiratory volume (MV), respiratory rate, and end-tidal carbon dioxide concentration were measured for both nasal and oral breathing before and after IMF. Pulse oximetry recordings were also taken. There was no significant effect of IMF on any parameter in the volunteers. Fifteen patients engaged in nasal breathing only both before and after surgery with IMF (group pN), and 7 patients had combined nasal and oral breathing before but only nasal breathing after IMF (group pNO). VT and MV decreased (536-357 mL and 7.84-5.40 L, respectively) in group pNO after IMF. These results suggest that assessment of the preoperative breathing status is helpful in predicting postoperative respiratory function after IMF and indicate that patients with preoperative mouth breathing require greater respiratory care after general anesthesia with IMF.

Neurosensory differences after wire and rigid fixation in patients with mandibular advancement

PURPOSE

The purpose of this analysis was to compare the frequency and severity of nerve damage with rigid and wire fixation in patients participating in a prospective, randomized clinical trial.

PATIENTS AND METHODS

One hundred twenty-six patients who required a bilateral sagittal split osteotomy and mandibular advancement were randomly assigned to receive either rigid or wire fixation. Tactile sensation in the mental nerve region bilaterally was determined presurgically and throughout the subsequent 2 years by using monofilament detection and brush stroke direction. Neurosensory levels were compared between the types of fixation over time.

RESULTS

Evaluation with monofilament detection showed no significant difference between types of fixation throughout the 2-year follow-up. However, brush stroke determination showed significantly greater hypesthesia with rigid compared with wire fixation from 8 weeks through 2 years postoperatively.

CONCLUSION

Rigid fixation resulted in more anesthesia in the mental nerve distribution than wire fixation when tested with brush stroke direction. However, increased anesthesia was not present when measured with monofilament determination.

Surgical risk factors for condylar resorption after orthognathic surgery

OBJECTIVE

The purpose of this study was to look for surgical risk factors for condylar resorption after orthognathic surgery.

STUDY DESIGN

Seventeen patients of a group of 452 patients who had undergone orthognathic surgery consecutively and who were in accordance with the inclusion criteria of this study showed postoperative condylar resorption (group I). Preoperative cephalometric characteristics and surgically induced movements of this group were compared with a control group of 17 of 452 patients (group II) in whom postoperative condylar resorption and skeletal relapse did not develop, despite mandibular retrognathism (ANB angle >4 degrees) and high mandibular plane angle (>40 degrees).

RESULTS

The kind of osteosynthesis used was not significantly different between the 2 groups. The amount of surgical advancements and the vertical movements of the jaws were not significantly different between the 2 groups. However, the distal (P =.005) and proximal (P =.007) mandibular segments were rotated significantly further counterclockwise in group I. Surgically induced posterior condylar displacement occurred significantly more frequently (P =.007) in group I.

CONCLUSIONS

Counterclockwise rotation of the distal and proximal mandibular segments and surgically induced posterior condylar displacement seem to be important surgical risk factors for postoperative condylar resorption. Therefore, these movements seem to be contraindicated in patients who are at high risk.

The role of a posteriorly inclined condylar neck in condylar resorption after orthognathic surgery

Recently, it has been reported that a posteriorly inclined condylar neck is associated with condylar resorption following orthognathic surgery, although its role in resorption remains unknown. By cephalometric screening of 240 patients with Angle Class II occlusion 2 years after orthognathic surgery, 11 patients with postoperative condylar resorption were identified. The preoperative posterior inclination of the condylar neck and the surgical risk factors mentioned in the literature, particularly surgically induced counterclockwise rotation of the mandibular proximal segment were evaluated. In all 11 cases, the condylar neck was clearly inclined posteriorly. Counterclockwise rotation of the proximal segment was also observed in all cases, and it amounted to 6.7 degrees (2.5-12 degrees) on average. The contributing role of a posteriorly inclined condylar neck in connection with surgical mandibular movement in postoperative condylar resorption is discussed.

Complication rates associated with different treatments for mandibular fractures

PURPOSE

This study compared the complication rate with different types of mandibular fracture treatment (maxillomandibular fixation, 2-mm miniplates, 2.4-mm AO plates, and 2.7-mm AO plates).

PATIENTS AND METHODS

A total of 245 patients who presented with 386 fractures were retrospectively analyzed. Patient characteristics, type of fracture, severity of fracture, type of treatment used, and occurrence of complications were recorded. Statistical analysis was used to compare complication rates, fracture severity, and type of treatment.

RESULTS

There were no differences in the complication rates for the different types of treatment. There was a significant correlation (P < .05) between fracture severity and the overall complication rate, postoperative infection, and postoperative malocclusion, but there was no significant correlation between these complications and the type of treatment applied.

CONCLUSION

The occurrence of postoperative complications in the treatment of mandibular fractures is fundamentally related to the severity of the fracture rather than to the type of treatment used.