Management Of Mandibular Angle Fractures Research Articles

A Prospective Study of Strut versus Miniplate for Fractures of Mandibular Angle

This prospective randomized clinical trial compared the treatment outcomes of strut plate and Champy miniplate in fixation of mandibular angle fractures. Patients with mandibular angle fracture were consented and enrolled into this study. Exclusion criteria include patients with severely comminuted fractures. The patients were randomly assigned to receive the strut plate or Champy miniplate for angle fracture fixation. Patient demographics, fracture characteristics, operative and postoperative outcomes were collected prospectively. Statistical analysis was performed to evaluate the significance of the outcome. A total of 18 patients were included in this study and randomly assigned to receive either the strut plate or Champy miniplate. Out of which five patients were excluded postoperatively due to complex fracture resulting in postoperative maxillomandibular fixation. The final enrollment was 13 patients, N = 6 (strut) and N = 7 (Champy). There was no statistically significant difference in the pretreatment variables. Nine of these patients had other associated facial fractures, including parasymphyseal and subcondylar fractures. Most of the (11) patients had sufficient follow-up after surgery. Both groups exhibited successful clinical unions of the mandibular angle fractures. The complications associated with the mandibular angle were 20% in the strut plate group and 16.7% in the Champy group. One patient in the strut plate group had a parasymphyseal infection, requiring hardware removal. The strut plate demonstrated comparable surgical outcome as the Champy miniplate. It is a safe and effective alternative for management of mandibular angle fracture.

A Prospective Study on Management of Mandibular Angle Fracture.

To evaluate the results of management of mandibular angle fracture by open reduction and internal fixation using single non compression miniplate via transbuccal, intraoral or extraoral approaches. In this prospective study, 30 patients were randomly selected regardless of age, sex requiring open reduction and internal fixation of non comminuted angle fracture with/or without other associated fractures of the mandible. All the patients were operated under general anaesthesia following routine haematological, biochemical, general physical examination and routine radiographic examination. Patients were randomly distributed into 3 groups namely: (1) intraoral, (2) transbuccal, and (3) extraoral groups depending on the surgical approach used for open reduction and internal fixation of fracture of the angle of mandible. In the intraoral group (12 patients), angle fracture was approached through the intraoral vestibular incision similar to sagittal split incision. In the transbuccal group (8 patients), angle fracture was approached through the intraoral vestibular incision and transbuccal stab incision for screw fixation via trochar. In the extraoral group (10 patients), angle fracture was approached through the Risdon's submandibular incision. In all the patients, fractures were reduced with upper and lower Erich's arch bar fixation as means for IMF intraoperatively. In all the patients, fracture of the angle of the mandible was fixed with single non compression 2.5mm, 4 holed with gap stainless steel miniplate and 6/8mm monocortical screws. All patients were followed up for minimum of 6months to maximum of 24months. Complications were relatively minor such as paresthesia (on average 26.7% first post-operative day which was gradually improved and on average after 1month was 3.3%), mild to moderate occlusal discrepancies (on average 36.7%) which needed the post-operative intermaxillary fixation with elastics for 1-2weeks, infection (20% on average) was mild to moderate which was managed with antibiotic therapy and/or incision and drainage except in one case, plate removal was done under general anaesthesia (extraoral group) because of recurrent infection. Post-operative pain was mild to moderate (mean VAS score pre operative-6.17, post-operative 1week-1.63) which was managed with analgesics. Mouth opening was recorded in all patients which was on average 20.98mm preoperatively which improved to 40.57mm after 1month. The use of a single non compression miniplate for fractures of the angle of the mandible is a simple, reliable technique with relatively rare major complications and few minor complications irrespective of the surgical approach used for the open reduction.

Poster 98: Management of Mandibular Angle Fracture Using 3d Strut Plates - A Pilot Study

The use of rigid fixation methods have been the mainstay in the management of mandibular angle fractures. However these were associated with high complication rates owing to huge implant load, greater periosteal stripping and disruption of vascular supply. The introduction of semirigid fixation methods using Champy's 2 mm miniplate at the inferolateral border of the external oblique ridge transorally has been proved to have the best clinical outcomes, least complications and easier to apply1.

A Review of Mandibular Angle Fractures

AFTER STUDYING THIS ARTICLE, THE READER WILL BE ABLE TO: (1) review the incidence and etiology of mandibular angle fractures; (2) gain an understanding of patient evaluation and general management principles; and (3) discuss indications and available techniques for management of mandibular angle fractures. Angle fractures represent the highest percentage of mandibular fractures. Two of the most common causes of mandibular angle fractures are motor vehicle accidents and assaults or altercations. With any patient who has sustained facial trauma, a thorough history and comprehensive physical examination centering on the head and neck region as well as proper radiological assessment are essential. These elements are fundamental in establishing a diagnosis and developing an appropriate treatment plan for any mandibular fracture.

Versatility of a single upper border miniplate to treat mandibular angle fractures: A clinical study

Context:Mandibular fractures are among the most common of facial fractures. Fractures of the mandibular angle are associated with the highest incidence of postsurgical infection of all mandibular fractures. The treatment of facial fractures has traditionally involved reestablishment of a functional dental occlusion with various types of intermaxillary fixation. Treatment modalities range from simple maxillo-mandibular fixation to rigid internal fixation of the bone fragments.Aims:The aim of this study was to determine the versatility of the single noncompression miniplate to treat the fractures of the mandibular angle with access via an intraoral route.Materials and Methods:Cases of unfavorable fractures of the mandibular angle were selected for the study of intraoral surgical management of mandibular angle fractures using a single 2.0-mm noncompression miniplate.Statistical Analysis and Results:An observational study was carried out on treatment of fractures of the angle of the mandible, and the findings were recorded and presented.Conclusions:We studied the versatility of the single noncompression miniplate to treat the fractures of the mandibular angle and found no complications associated with superior border miniplate fixation of mandibular angle fractures.

Clinical research of endoscopy-assisted open reduction and internal fixation for the management of mandibular angle fractures

Objective Management of mandibular angle fractures was often challenging.The report was to describe the application of endoscopy in the open reduction and rigid fixation by the transoral approach for the management of mandibular angle fracture when the Champy technique was not indicated.Methods A series of 34 patients with 37 sides of serious mandibular angle fractures was admitted for endoscopy-assisted surgery,of which 22 sides were unfavorable fractures with one fissure,13 sides were complicated fractures,and 2 side wascomminuted fracture.Monocortical fixation by the transoral approach was performed with one minipalte at the superior border of the mandible medial to the external oblique line and one miniplate at the inferior border with the aid of a percutaneous trocar.Results Adequate anatomic reduction and pretraumatic occlusion were achieved under the supervision of endoscope with intermaxillary fixation except one patient who achieved functional reduction.The physical examination and radiological imaging demonstrated no infection,nerve deficiency,malocculsion or other complications.Conclusion The endoscopy-assisted open reduction and two rigid fixation with miniplates by the transoral approach prove to be a reliable surgical method for the management of unfavorable,severely dislocated,or complicated mandibular angle fractures when the Champy technique is not indicated.The technique has the advantage of minimally invasive surgery. Key words: Mandibular angle; Fracture; Rigid internal fixation; Endoscopy

Sentinel Articles in Craniomaxillofacial Trauma

Over the years, a great many authors have added to the body of knowledge in the area of craniomaxillofacial trauma. Reports of new approaches, techniques, reviews, and data analysis have all added to our knowledge and armamentarium. A few can be considered sentinel in that they either validated or changed the way things were managed. In this and forthcoming issues, we will review an article of the past and note how it impacted management. The inaugural sentinel article is selected from the Spring 1996 issue of the Journal of Craniomaxillofacial Trauma (Ellis E III. Treatment methods for fractures of the mandibular angle. J Craniomaxillofac Trauma 1996;2[1]:28–36). In this article, Ellis summarized six studies in which he and his colleagues reported on accepted methods for treatment of fractures of the mandibular angle. These included nonrigid fixation and a variety of rigid fixation techniques with convalescent function. The patients were comparable: all from an inner city indigent population. The fractures were comparable: the complication-prone mandibular angle. The surgeons were comparable. This was perhaps the first and only time comparable data on mandibular fractures were assembled and reported comparing “apples to apples.” The results of these studies were startling to say the least. Dynamic compression, the “gold standard” for absolute immobilization, paled in comparison to semirigid fixation with a single transoral miniplate with respect to major complications (32% versus 2.5%). Two-plate fixation for angle fractures was, for many surgeons, now relegated to the “historical approach” category. This article established the evidence base for using either a noncompression miniplate placed on the superior border transorally or a transfacially placed reconstruction plate as the rigid internal fixation technique for the management of mandibular angle fractures.

Ridge plates versus transbuccal plates in the management of mandibular angle fractures; a prospective randomised trial

Aim: To assess whether there is a difference between the postoperative infection rate, occlusion and anatomical reduction of fractures of the angle of the mandible treated by an osteosynthesis plate positioned on the external oblique ridge via an intraoral approach or on the lateral aspect of the mandible via a transbucaal approach. Study design: A prospective randomised trial. Ethics committee approval was obtained and 350 consecutive patients, who provided consent, were entered into the trial over a period of 2½ years. Statistical analysis was performed using Fisher's Exact Test and Pearson Chi-Square Test. Results: Infection resulted in plate removal in 13% of patients. Fractured angles of the mandible treated via a transbuccal approach experienced significantly less infection ( P < 0.000). Smoking is related to increased risk of postoperative infection ( P < 0.00). Analysis was also made of oral hygiene, degree of fracture displacement, delay between incident and operative procedure, method of fracture reduction, alcohol consumption and postoperative occlusion. Conclusion: Fractures of the angle of the mandible should managed with an osteosynthesis plate placed on the lateral aspect of the mandible via a transbuccal approach.

The addition of a locking plate to a modified transbuccal retractor confers increased stability and easier soft tissue control in the application of miniplates in the management of mandibular angle fractures

he transbuccal approach for the application of miniplates n the management of proximal fractures of the mandibular ody and angle is well described.1 Various frictional male o female part connectors have been employed by different anufacturers to affect a lock between the two parts of the ransbuccal retractor: the buccal retractor and the transbuccal annula and handle. However, it is our experience that this ften disengages at some point during a procedure. This is specially so when placing longer plates where the soft tissue raction is most forceful, e.g. when placing screws at each end f a six hole miniplate. The locking plate secured transbuccal retractor comprises everal parts: the buccal retractor, handle and transbuccal annula, the locking plate, drill bit cannula and trocar. The etractor has been designed to be used with a Medicon minilate plating system in the internal fixation of mandibular ngle fractures. The device is employed in the usual manner: he fracture exposed and reduced, dental occlusion controlled nd the transbuccal cannula introduced with the trocar in situ. his is passed through the buccal soft tissues until the tip of he cannula rests on bone. We prefer to start this with a stab ncision using the tip of a size 15 blade. The trocar is removed. he split beaks of the buccal retractor are placed either side

One miniplate versus two in the management of mandibular angle fractures: A prospective randomised study

We compared the use of one miniplate ( n = 36) with that of two miniplates ( n = 26) for the treatment of the mandibular angle in a randomised trial. There were no significant differences between the groups in total morbidity (22/36 compared with 14/26) or for individual complications. We conclude that two miniplates seem to confer no extra benefit to patients, but a much larger trial would be required to show this conclusively.

Treatment Modalities for Mandibular Angle Fractures

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. 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. 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). 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.

Technique for applying 2 miniplates for treatment of mandibular angle fractures

When using Champy's method1 for the management of mandibular angle fractures, a separation of the fracture line and lateral displacement of the fragments at the lower mandibular border are often observed. In addition a posterior open bite on the side of the fracture is frequently observed immediately after fixation of the mandibular angle fracture at the superior border. To achieve primary intraoperative anatomic alignment and stable fixation of the fracture, a 2-miniplate fixation technique is used in which one plate is applied at the superior border and a second at the inferior border of the mandible.