Mandibular osteosynthesis by miniature screwed plates via a buccal approach

The modified Michelet's (1973) technique of mandibular osteosynthesis, which consists of monocortical juxta-alveolar and sub-apical osteosynthesis, without compression and without inter-maxillary fixation, is described. This technique can be used in many types of mandibular fracture, single or multiple, associated or isolated, except in the case of a fracture of the condylar neck and in the presence of pre-existing infection. Infected fractures are treated by orthopaedic methods. Materials used (plates and screws) and particulars of the method have been tested by multi-disciplinary experimentation, particularly by anatomical verification and biomechanical studies. The ideal line of osteosynthesis is described. For the author, this technique is a routine treatment of any type of mandibular fracture.

Indications for open reduction of mandibular condyle fractures

Most condylar fractures of the mandible may be treated by closed reduction and appropriate physiotherapy. Some, however, absolutely should be opened and reduced anatomically; with others, good arguments for open reduction may be offered. This article reviews the possible indications for open reduction and presents an approach that conceals the scar.

Open versus closed treatment of fractures of the mandibular condylar process-a prospective randomized multi-centre study

AIM

The aim of this international prospective randomized multi-centre study was to compare operative and conservative treatment of displaced condylar fractures of the mandible.

METHODS AND PATIENTS

Out of a total of 88 randomized patients from 7 centres, 66 patients with 79 fractures of the mandibular condylar process completed the study and were evaluated. All fractures were displaced, being either angulated between 10 degrees and 45 degrees or the ascending ramus was shortened by more than 2mm. The follow-up examinations 6 weeks and 6 months following treatment included evaluation of radiographic measurements, clinical, functional and subjective parameters including visual analogue scale for pain and the Mandibular Function Impairment Questionnaire index for dysfunction.

RESULTS

Correct anatomical position of the fragments was achieved significantly more often in the operative group in contrast to the closed treatment group. Regarding mouth opening/lateral excursion/protrusion, significant (p=0.01) differences were observed between both groups (open 47/16/7mm versus closed 41/13/5mm). The visual analogue scoring revealed significant (p=0.03) differences with less pain in the operative treatment group (2.9 open versus 13.5 closed). The Mandibular Function Impairment Questionnaire index recorded a significant (p=0.001) difference with less pain and discomfort in the open treatment group (10.5 versus 2.4 points).

CONCLUSION

Both treatment options for condylar fractures of the mandible yielded acceptable results. However, operative treatment, irrespective of the method of internal fixation used, was superior in all objective and subjective functional parameters.

Fractures of the mandibular condyle: A review of 466 cases. Literature review, reflections on treatment and proposals

INTRODUCTION

The incidence of condylar fractures is high. Condylar fractures can be extracapsular (condylar neck or subcondylar) or intracapsular, undisplaced, deviated, displaced or dislocated. Treatment depends on the age of the patient, the co-existence of other mandibular or maxillary fractures, whether the condylar fracture is unilateral or bilateral, the level and displacement of the fracture, the state of dentition and the dental occlusion, and the surgeon's experience.

PURPOSE

This report presents the experience acquired in the treatment of 466 condylar fractures over 7 years, reviews the pertinent literature and proposes guidelines for treatment.

MATERIAL AND METHODS

The archives of KAT, General District Hospital between 1995 and 2002 were scrutinized and the condylar fractures were recorded. The aetiology, age, sex, level of fracture, degree of displacement, associated facial fractures, malocclusion, and type of treatment were noted.

RESULTS

Four hundred and sixty-six condylar fractures were admitted, the male:female ratio was 3.5:1. Road traffic accidents were the main cause and most fractures were unilateral, displaced, subcondylar, occurred on the left side and were treated conservatively.

CONCLUSIONS

Early mobilization is the key in treating condylar fractures. Whilst rigid internal fixation provides stabilization and allows early mobilization, conservative treatment is the treatment of choice for the majority of fractures. Children and intracapsular fractures are treated conservatively with or without maxillo-mandibular fixation. Open reduction is recommended in selected cases to restore the occlusion, in severely displaced and dislocated fractures, in cases of loss of ramus height, and in edentulous patients. It may be considered in those with 'medical problems' where intermaxillary fixation is not recommended.

Fractures of the mandible: a review of 580 cases

The anatomic distribution of fractures in this study showed more fractures of the condylar and parasymphysis/symphysis regions, with correspondingly fewer body and angle fractures, than in other reported studies. The site of fracture is related to the type of trauma involved. Altercations, in which most force is directed in a single blow to the lateral aspect of the jaw, tend to result more frequently in angle and body fractures and less often in condylar, symphysis, and alveolar fractures. Automobile accidents, which more frequently involve trauma to the anterior mandible, result in more fractures of the symphysis region, alveolus and condyle. Motorcycle accidents produce many more alveolar fractures, suggesting that the traumatic force in this kind of accident is often directed to the alveolus. As might be expected, those individuals involved in motor vehicle accidents had the highest incidence of other injuries in addition to the mandibular fractures. Injuries to the head and neck were most common, but a wide variety of other injuries occurred. Complications are more common in the patient who has sustained multiple trauma. Most fractures were treated by closed reduction. When open reduction was necessary, the most common sites were the angle, body, and symphysis regions.

Surgical complications with open treatment of mandibular condylar process fractures

PURPOSE

This study assessed the surgical complications after open treatment for fractures of the mandibular condylar process.

PATIENTS AND METHODS

A total of 178 patients with unilateral fractures of the mandibular condylar process, 85 treated closed and 93 treated open, were included in this study. A tabulation of surgical findings and intraoperative and postoperative complications was prospectively performed. Standardized animating facial photographs were obtained at several postsurgical intervals and were examined and scored by a prosthodontist and an orthodontist for signs of facial nerve palsy and the quality of the surgical scar. Standard statistical methods were used to assess differences between open and closed treatment groups.

RESULTS

There were very few intraoperative or postoperative complications. At the 6-week point, 17.2% of patients treated open had some weakness of their facial nerve. This had resolved by 6 months. The scars were judged either wide or hypertrophic in 7.5% of cases.

CONCLUSIONS

Based on this study, surgical complications of open treatment of condylar process fractures that lead to permanent dysfunction or deformity are uncommon.

Small plate osteosynthesis of mandibular fractures

Small plate osteosynthesis has been evaluated by comparing 50 successive cases of mandibular fracture treated by this technique alone with 50 successive cases of mandibular fracture treated by intermaxillary fixation. The plates show considerable advantages over other forms of fixation in that they are small, malleable and easy to insert. Furthermore, they achieve a high degree of stability. The rate of recovery of normal jaw function and normal body weight is significantly greater than with intermaxillary fixation.

Rigid fixation of mandibular condyle fractures

This article reviews the anatomy and surgical approaches for treating fractures of the mandibular condyle with plate and screw fixation. Advantages and disadvantages of the preauricular, submandibular, intraoral, retromandibular, and rhytidectomy approaches are presented.

Treatment of mandibular angle fractures using one noncompression miniplate

PURPOSE

This study evaluated the results in patients treated for fractures of the mandibular angle with a single miniplate.

PATIENTS AND METHODS

Eighty-one patients with fractures of the mandibular angle were treated by open reduction and internal fixation using one noncompression miniplate with 2.0-mm self-threading screws placed through a transoral incision. No patient was placed into postsurgical maxillomandibular fixation. They were prospectively studied for complications.

RESULTS

Thirteen patients with angle fractures (16%) experienced complications requiring secondary surgical intervention. Most of the complications (n = 11), however, were minor and could be treated in the office. Most commonly, intraoral incision and drainage and later removal of the bone plate were required. All patients with minor complications had clinical union. Only two complications required hospitalization for intravenous antibiotics and further surgery. One of these patients had a fibrous union requiring a bone graft.

CONCLUSIONS

The use of a single miniplate for fractures of the angle of the mandible is a simple, reliable technique with a relatively small number of major complications.

Repair of canine mandibular bone defects with bone marrow stromal cells and porous beta-tricalcium phosphate

Tissue engineering has become a new approach for repairing bone defects. Previous studies have been limited to the use of slow-degradable scaffolds with bone marrow stromal cells (BMSCs) in mandibular reconstruction. In this study, a 30 mm long mandibular segmental defect was repaired by engineered bone graft using osteogenically induced autologous BMSCs seeded on porous beta-tricalcium phosphate (beta-TCP, n=5). The repair of defects was compared with those treated with beta-TCP alone (n=6) or with autologous mandibular segment (n=4). In the BMSCs/beta-TCP group, new bone formation was observed from 4 weeks post-operation, and bony-union was achieved after 32 weeks, which was detected by radiographic and histological examination. In contrast, minimal bone formation with almost fibrous connection was observed in the group treated with beta-TCP alone. More importantly, the engineered bone with BMSCs/beta-TCP achieved a satisfactory biomechanical property in terms of bending load strength, bending displacement, bending stress and Young's modulus at 32 weeks post-operation, which was very close to those of contralateral edentulous mandible and autograft bone (p>0.05). Based on these results, we conclude that engineered bone from osteogenically induced BMSCs and biodegradable beta-TCP can well repair the critical-sized segmental mandibular defects in canines.

Outcomes of open versus closed treatment of mandibular subcondylar fractures

OBJECTIVES

The purpose of this study was to compare the long-term treatment results of open reduction and rigid internal fixation (ORIF) with closed reduction and maxillomandibular fixation (CRMMF) for subcondylar fractures when guided by specific indications and contraindications.

PATIENTS AND METHODS

A protocol for the treatment of condylar process fractures was developed that included absolute and relative indications and contraindications as well as a technique regimen. To evaluate the results of this protocol, 10 patients treated with CRMMF and 10 treated by ORIF were recalled after a minimum of 6 months and examined for gender, race, diagnosis, age at injury, time since operation, and cause of the fracture. Each group was assessed by 2 blinded investigators for maximum interincisal opening, right lateral excursion, left lateral excursion, protrusive movement, deviation on opening, scar perception, motor function, sensory perception, contour perception, occlusion, and perception of pain. Nonparametric data were compared for statistical significance with a chi-square analysis and parametric data with an independent samples t-test (P < .05).

RESULTS

No statistically significant differences existed between the ORIF and CRMMF groups for gender, race, diagnosis, or cause. Moreover, no differences existed for age at injury, maximum interincisal opening, right lateral excursion, left lateral excursion, protrusive movement, deviation on opening, or occlusion. Differences were noted between groups for time since operation, scar perception, and perception of pain. Using the protocol outlined, there were no differences between the ORIF and CRMMF groups for ranges of motion, occlusion, contour, and motor or sensory function. The ORIF group was associated with perceptible scars. The CRMMF group was associated with chronic pain.

CONCLUSIONS

Using a treatment protocol, there were few differences in outcomes between patients treated with CRMMF and ORIF for subcondylar fractures.

Bite forces in patients treated for mandibular angle fractures: implications for fixation recommendations

Voluntary bite forces were recorded at varying periods in 35 males treated with rigid internal fixation for fractures of the mandibular angle. Bite forces were also obtained in 29 male controls for comparison. It was found that molar bite forces in patients were significantly less than in controls for several weeks after surgery. Further, molar bite forces on the side of the fracture were significantly less than on the nonfractured side. The results of this study indicate that recommendations for the amount of fixation required for a given fracture may be reduced.

Occlusal results after open or closed treatment of fractures of the mandibular condylar process

PURPOSE

This study compared the occlusal relationships after open or closed treatment for fractures of the mandibular condylar process.

PATIENTS AND METHODS

A total of 137 patients with unilateral fractures of the mandibular condylar process (neck or subcondylar), 77 treated closed and 65 treated open, were included in this study. Standardized occlusal photographs obtained at several postsurgical time intervals were examined and scored by a surgeon and an orthodontist. Standard statistical methods were used to assess differences between groups.

RESULTS

Patients treated by closed techniques had a significantly greater percentage of malocclusion compared with patients treated by open reduction, in spite of the fact that the initial displacement of the fractures was greater in patients treated by open reduction.

CONCLUSIONS

Based on this study, more consistent occlusal results can be expected when fractures of the mandibular condylar process are treated by open reduction.

Retrospective Study of 1251 Maxillofacial Fractures in Children and Adolescents

BACKGROUND

Fractures of the facial skeleton are relatively uncommon in children and adolescents, and only a few reports review a significant number of patients. The authors performed a retrospective study to analyze the different characteristics of such fractures in the pediatric population of Portugal.

METHODS

The authors reviewed the clinical records of a series of 912 patients 18 years of age or younger with facial fractures treated by the Departments of Plastic, Reconstructive, and Aesthetic Surgery and of Maxillofacial Surgery, São João Hospital, in Porto, Portugal, between the years 1993 and 2002. The following parameters were evaluated: age; sex; cause of accident; hour, day, and month of hospital admission; location and type of fractures; presence and location of associated injuries; treatment methods; length of in-hospital stay; and complications.

RESULTS

A total of 1251 fractures were treated. The ratio of boys to girls was 3.1:1. Patients between 16 and 18 years old were the major group (47.8 percent). Motor vehicle accident was the most common cause of injury (53.3 percent of patients). Mandibular fracture was the most common type of fracture (48.8 percent). Associated injuries occurred in 558 patients (64.5 percent).

CONCLUSIONS

Pediatric facial fractures are usually associated with severe trauma. The number of fractures caused by automobile accidents has decreased (p < 0.05). The incidence of this type of fracture is high in Portugal.

Infection after rigid internal fixation of mandibular fractures: a clinical and radiologic study

Of 214 patients with mandibular fractures treated following the AO/ASIF principle of rigid fixation, 13 patients (6.1%) developed postoperative infection. The yearly percentage decreased remarkably during the study period. When rigid fixation became a routine method, the infection rate was as low as the corresponding figure for cases treated with nonstable techniques and maxillomandibular fixation (MMF). All but one of the infected fractures were in the angular region of the mandible. Teeth had been extracted from the fracture line in 9 of the 10 dentulous patients. It was concluded that erroneous techniques had been used in almost all infected cases, because compression could not be achieved when there was an irregular fracture line, an atrophic edentulous mandible, or inadequate stability due to removal of a tooth in the line of fracture. In five patients, successful reoperation was performed using a reconstruction plate. Detailed radiologic examination was useful in assessment of infection and in follow-up.

Surgical versus nonsurgical treatment of unilateral dislocated low subcondylar fractures: a clinical study of 52 cases

To compare open versus closed reduction of unilaterally dislocated low subcondylar fractures in adults, 101 consecutive dentulous patients were treated either by closed reduction with a median of 4 weeks of maxillomandibular fixation, or with a median of 6 weeks of maxillomandibular fixation after surgical repositioning and transosseous wiring of the dislocated condylar fragment. No selection of patients was done for either treatment. Fifty-two patients were seen at a median of 2 years postoperatively. Complications such as malocclusion, mandibular asymmetry, impaired masticatory function, and pain located to the affected joint or masticatory muscles were seen significantly more frequent in patients treated with closed reduction compared with those treated surgically (P = .005). Neither the degree of dislocation of the proximal fragment, concomitant mandibular fractures, nor the absence of posterior occlusal support seemed to influence the results.

Use of resorbable plates and screws in pediatric facial fractures

PURPOSE

The use of resorbable plates and screws for fixation of pediatric facial fractures is both well tolerated and effective. It enables realignment and stable positioning of rapidly healing fracture segments while obviating any future issues secondary to long-term metal retention.

PATIENTS AND METHODS

Forty-four pediatric facial fractures were treated over a 10-year period at our institution using differing techniques of polymeric bone fixation. Twenty-nine mandible fractures in patients under the age of 10 (age range, 6 months to 8 years) were treated. Displaced fractures of the symphysis, parasymphysis, body, and ramus underwent open reduction and either 1.5-mm or 2.0-mm plate and screw fixation in 14 patients. Subcondylar fractures were treated by a short period of maxillomandibular fixation (3 weeks) achieved with suture ligation between resorbable screws placed at the zygoma and symphysis or a circummandibular suture attached to a zygomatic screw. Fifteen patients (age range, 4 to 11 years) with isolated frontal, supraorbital, intraorbital, or orbitozygomatic fractures were treated by open reduction and internal fixation with 1.5-mm resorbable plates, mesh, and screws.

RESULTS

No long-term implant-related complications were seen in any of the treated patients.

CONCLUSIONS

Resorbable polylactic and polyglycolic acid plates and screws can be an effective fixation method for facial fractures in children in the primary and secondary dentition periods.

The use of miniplates in mandibular fractures. An in vitro study

To test the stability of miniplate osteosynthesis in the mandible, a three-dimensional in vitro model was developed. Four clinically relevant fracture situations were simulated by osteotomies in polyurethane mandibles. The stability of the osteosyntheses was tested according to a reproducible procedure of unilateral loading under conditions of static equilibrium. The mandible was supported at the condyles in silicon rubber fossae and was held in position by traction on the coronoid processes in combination with preloading in the region of the incisors with a force of 10 N. Six points were tested to register the effects of unilateral loading on bending and torsion at the sites of the osteotomies. The following results were obtained. The preliminary results show that in cases of jaw angle fracture neither bending nor torsional forces are sufficiently controlled by miniplate-fixation in the commonly proposed position. Furthermore, it was confirmed that fracture treatment in the canine region requires two plates instead of one to resist displacement of the fracture fragments during function.

Treatment modalities for mandibular angle fractures

PURPOSE

Management of mandibular angle fractures is often challenging and results in the highest complication rate among fractures of the mandible. Optimal treatment for angle fractures remains controversial. Historically, treatment of mandible fractures included intraoperative maxillomandibular fixation (MMF) along with rigid internal fixation. More recently, noncompression plates miniplates, which produce only relative stability, have gained popularity. The absolute necessity of intraoperative MMF as an adjunct to internal fixation has also become controversial. The current trends in the management of simple, noncomminuted mandibular angle fractures are examined.

MATERIALS AND METHODS

A survey was submitted to North American and European AO ASIF (Arbeits-gemeinschaft fur Osteosynthesefragen Association for the Study of Internal Fixation) faculty in July 2001. Statistical analysis of results included both Fisher's exact and chi-square tests. Results were considered significant if P <.05.

RESULTS

One hundred ten of 127 potential responses were received (87%). Among 104 surgeons who treat mandible fractures, 86 (83%) treat more than 10 mandibular fractures per year. Preferred techniques for simple, noncomminuted mandibular angle fractures in this group were: single miniplate on the superior border (Champy technique) with or without arch bars (44 surgeons, 51%); tension band plate on the superior border and nonlocking, bicortical screw plate on the inferior border (11 surgeons, 13%); dual miniplates (9 surgeons, 10%); a locking screw plate on the inferior border only (6 surgeons, 7%), and 3-dimensional plates (5 surgeons, 6%). Eleven surgeons (13%) gave multiple answers. Although only 13% of surgeons surveyed primarily use the combination of tension band and nonlocking, bicortical screw plates, many surgeons (73%) continue to use this technique in certain circumstances. Within this group, 32 (51%) place screws in a neutral position, while 31 (49%) place screws in an eccentric position, resulting in compression. For simple noncomminuted angle fractures, the number of surgeons performing internal fixation without MMF were: 14 often (16%); 20 occasionally (23%); 17 seldom (20%); and 35 never (41%). Surgeons treating more than 10 versus those who treat less than 10 fractures per year, International versus North American faculty, and Oral and Maxillofacial surgeons (OMS) versus non-OMS surgeons were compared. Surgeons who treat more than 10 fractures per year favor the Champy technique over the tension band and bicortical plate combination (44 [51%] vs 11 [13%]), while those surgeons who treat less than 10 per year favor the tension band and bicortical plate combination over the Champy technique (9 [50%] vs 3 [17%]; P < .01, Fisher exact test). International faculty are less likely to use intraoperative MMF than North American faculty (29 [81%] vs 31 [43%]; P < .01, Fisher exact test). OMS surgeons are less likely to use the tension band and bicortical plate combination than non-OMS surgeons (22 [56%] vs 42 [90%]; P < .017, Fisher exact test).

CONCLUSION

This survey suggests an evolution in the management of mandibular angle fractures. A single miniplate plate on the superior border of the mandible has become the preferred method of treatment among AO faculty. When using large, inferiorly based plates more surgeons are now favoring neutral rather than eccentric screw placement. Intraoperative MMF is not considered mandatory by some surgeons in certain circumstances.

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.

Comparison of functional recovery after nonsurgical and surgical treatment of condylar fractures

This article evaluates 16 cases of condylar fracture treated surgically, comparing them with the 20 cases treated nonsurgically, with a 2-year follow-up. Although severely displaced and luxated fractures were involved in the surgical group with rigid internal fixation, satisfactory postoperative function and occlusion were achieved at the same level as in the nonsurgical group, without severe complications.

Treatment of mandibular angle fractures using two noncompression miniplates

PURPOSE

To evaluate treatment with two 2.0-mm noncompression miniplates for patients with angle fractures.

PATIENTS AND METHODS

Sixty-seven consecutive patients with 69 fractures of the mandibular angle were treated by open reduction and internal fixation using two noncompression miniplates and 2.0-mm self-threading screws placed through a transoral incision with transbuccal trochar instrumentation. No patient was placed into postsurgical maxillomandibular fixation or elastics.

RESULTS

Overall, 19 fractures (28%) experienced complications requiring secondary surgical intervention. Most of the complications were postoperative infections requiring surgical drainage (n = 17) and subsequent hardware removal (n = 16). Of the 17 infected fractures, 11 were healed at the time of hardware removal and required no further treatment. Five were still mobile and required a period of maxillomandibular fixation for healing. One of the fractures did not heal and required bone grafting.

CONCLUSION

The use of two noncompression miniplates was found to be relatively easy, but resulted in an unacceptable rate of infection in our patient population when used for treatment of fractures of the mandibular angle.

Ultrastructural findings in soft tissues adjacent to titanium plates used in jaw fracture treatment

The present study was conducted on biopsies from soft tissues overlying titanium miniplates that were used for the treatment of jaw fractures. The aim was to investigate the morphology of liberated titanium particles and cellular or ultrastructural changes in tissues adjacent to the miniplates. Conventional transmission electron microscope (TEM) images were used for ultrastructural investigation and identification of metal-dense particles. The presence of titanium was proved by an increase in the intensity of element-specific, inelastically scattered electrons from the primary beam. The results showed that 5-8 months after insertion of the plates and screws, there was weak cellular activity within the scar tissue overlying the plates without inflammatory cells. Most of the titanium particles were located extracellularly. The ultrastructural appearance of most of these particles suggested that titanium may be shaved off the plates or screws and may undergo cellular uptake and lysosomal degradation. The partially degraded titanium particles are then left in place after the phagocytic cells have been isolated by collagenous fibers and have finally perished.

Results of treatment of fractures of the atrophic edentulous mandible by compression plating: a retrospective evaluation of 84 consecutive cases

PURPOSE

This article introduces a simple and reproducible classification of the degree of atrophy in fractures of the atrophic edentulous mandible, and evaluates the results of treatment in 84 consecutive fractures based on this classification.

MATERIAL AND METHODS

Eight-four fractures of the edentulous mandible, with a height at the fracture site of < or = 20 mm, were included. Using the ratio of actual plate width to plate width on the postoperative radiograph, the actual height of the mandible at the fracture site was calculated. Twenty-five fractures (30%) were in the Class I atrophy group (height at the fracture site 16 to 20 mm), 33 fractures (39%) occurred in Class II atrophic mandibles (height 11 to 15 mm), and 26 fractures (31%) were seen in extremely atrophic Class III mandibles (height < or = 10 mm). The treatment was performed by compression plating without any postoperative MMF. Primary bone grafting was used in six cases (7%) because a partial bone defect was present at the fracture site.

RESULTS

In 81 (96.5%) of the 84 fractures an uncomplicated, solid, bony union was achieved. Three major complications occurred: one osteomyelitis and two nonunions. The two nonunions occurred in bilateral fracture of an extremely atrophied mandible (Class III atrophy). Minor soft tissue infections, without interference with fracture healing, were observed in six cases (7%).

CONCLUSIONS

Because there is an obvious relation between the height of the mandible and the incidence of complications in fracture healing, a special classification of the degree of atrophy is needed. In fractures of the extremely atrophic mandible (Class III atrophy) periosteal degloving should be avoided and supraperiosteal placement of plates is recommended. Compression osteosynthesis has proved to be a successful method, with minimal impairment of the patient and a low frequency of serious complications.