Management Of Mandibular Fractures Research Articles

Management of mandibular fractures: A comparative analysis of rigid internal fixation and steel wire osteosynthesis. (English-Portuguese)

(Reprint requests to Dr. R. L. Cruz, Rua Visconde Silva 52, sala 703, CEP: 22271-090, Botafogo RJ, Brazil)

Applied Surgical Anatomy for Mandibular Fracture Management

Superior labrum lesion from anterior to posterior (SLAP) often presents together with other shoulder pathologies such as rotator cuff tear (RCT), but it is uncertain if repairing both SLAP and RCT has superior clinical outcomes over isolated repairs of SLAP and RCT.This was a retrospective cohort study with prospectively collected data, reviewing 157 patients who underwent arthroscopic repair of either RCT, SLAP (type II lesion), or both. Before surgery and after 6 weeks, 12 weeks, and 24 weeks, shoulder objective range of motion and strength were measured, patient-reported function and pain was assessed by the modified L’Insalata questionnaire with a Likert scale, and complications after each repair were examined.At 24 weeks after surgery, the combined group (n = 22) and SLAP group (n = 47) had significantly higher forward flexion (165° ± 4° and 167° ± 4° vs. 154° ± 3°, P = .01 and P = .01), external rotation strength (82 ± 6 N, 81 ± 6 N vs. 61 ± 3 N, P = .01 and P = .01), and abduction strength (94 ± 14 N, 78 ± 8 N vs. 53 ± 3 N, P = .001 and P = .02) compared with the rotator cuff tear repair (RCR) group (n = 88). The combined group also had stronger internal rotation than the RCR group (107 ± 12 N vs. 72 ± 4 N, P = .02). Function and pain improved from “severe-moderate” to “moderate-mild” in all groups after surgery.Repairing RCT and SLAP tears together results in significant clinical benefits compared to repairing just RCT and analogous results against SLAP-only repair.

Treatment of comminuted mandibular fractures by closed reduction

Few topics concerning the management of mandibular fractures are as controversial as the treatment of comminuted mandibular fractures. A comminuted fracture represents a bone that has been splintered or crushed,’ pulverized,’ or broken into several pieces,” giving rise to many small fragments.“ Thus, for purposes of this discussion, comminution is defined as the presence of multiple fracture lines resulting in many small pieces within the same area of the mandible (ie, angle, body, ramus, symphysis). Analysis of reports involving the number of fractures per mandible demonstrate remarkable consistency, with a range of 1.3 to 1.8 fractures per patient.5 These are obviously not comminuted. Although there has been a rebirth of interest in traumatology as indicated by the plethora of articles in the past 15 years, the incidence of mandibular comminution is still difficult to ascertain. Recent reports on large numbers of mandibular fracture patients (approximately 4,000) have failed to mention either explicitly or implicitly the number or incidence of comminuted mandibular fractures.6-x Other reports imply the presence of comminution, but careful review of the data is equivocal with respect to mandibular comminution, other than use of the term.9,‘0 The spectrum from relatively simple fractures9 to avulsion” seems to be categorized as comminution. However, many large epidemiologic studies”-17 of mandibular fracture patients (approximately 10,800) either do not include or do not mention a category of mandibular comminution. The incidence of mandibular comminution can be carefully and tediously extracted from large series of

Cost-effectiveness analysis of open reduction/nonrigid fixation and open reduction/rigid fixation to treat mandibular fractures

When open reduction and internal fixation is indicated for the management of mandibular fractures, it is generally agreed that nonrigid fixation and rigid fixation represent acceptable treatment alternative. Opinions vary, however, regarding the cost-effectiveness of the two alternative. The purpose of this study was to compare the costs of these treatments of mandibular fractures that required open reduction and internal fixation. Cost-effectiveness analysis was used to determine the most efficient resource used to treat mandibular fractures requiring open reduction and internal fixation. Cost-effectiveness was defined as the treatment charges per successfully treated patient. Data were collected retrospectively from patients with mandibular fractures treated between 1991 and 1994. The patient's medical record and hospital billing record were used as data sources. To estimate treatment charges, the sample was divided into three groups: (1) group 1, patients treated with nonrigid fixation without postoperative complications, (2) group 2, patients treated with rigid fixation without postoperative complications, and (3) group 3, patients treated with either procedure who had postoperative complications. The study variables were grouped into two categories: clinical information and charges. Treatment charges for both treatments were estimated and compared. Data were collected for 12 patients in group 1 and 11 patients in group 2. Costs for rigid fixation averaged $1,468 more per patient than for nonrigid fixation in uncomplicated cases. There were 11 patients in group 3. The average cost to treat a postoperative complication was $11,637. Given the institution-specific treatment cost and the probability of complications, rigid fixation was a more cost-effective treatment than nonrigid fixation. Cost estimates for treating mandibular fractures may vary widely depending on practice patterns and complication rates. Despite these cost variations, one may determine the most cost-effective treatment alternative by estimating treatment costs of both uncomplicated and complicated cases and the postoperative complication rate.

A TREATMENT PROTOCOL FOR MANDIBLE FRACTURES

Mandibular fracture management has evolved over several decades, and controversies exist over ideal approaches for individual fractures. Treatment choices include closed versus open techniques, reduction methods and repair, and decision concerning intermaxillary fixation. Both the patient and the fracture characteristics have an impact on these choices. Patient factors include age, mandibular bone quality, dentition, patient reliability, and associated injuries. Fracture characteristics include favorability versus unfavorability, single versus multiple, location, and infection. This study was undertaken to develop and evaluate a management algorithm to determine the best treatment of mandible fractures. Sixty-seven patients were managed at the Grady Memorial Hospital otolaryngology service. Ages ranged from 3 to 68 years and included 55 male patients and 12 female patients. Forty-three patients had multiple fractures, while 24 had single fractures. Sixty-four patients were successfully managed and had normal function on follow-up examination. Eleven patients (16.4%) had complications. These included three infections, one malunion, two malocclusions, and five marginal nerve pareses. Multiple fractures did not have a higher incidence of complication. This protocol allows an orderly approach to the successful outcome of mandibular fractures.

Management of mandibular fractures.

The complex physiology of the masticatory system is extremely sensitive to its intricate anatomic relationships. With the ever-increasing number of patients admitted to our institution with traumatic facial injuries, it seemed an appropriate time to evaluate the most widely employed treatment modalities available for the management of mandibular fractures. Maxillomandibular fixation remains the mainstay of mandible fracture stabilization. Within recent years, rigid internal fixation with miniplates and screws has become popular. This study compares the results of the most commonly used treatment modalities available for the repair of acute mandibular fractures.

The relationship between fracture severity and complication rate in miniplate osteosynthesis of mandibular fractures

There are many factors influencing the outcome of mandibular fracture management; however, the relationship between fracture severity and complication rate has only been recognised intuitively due to the absence of an accepted system of classification of the severity of these fractures. In 1989 Cooter and David described the alpha numeric system of computer based coding for craniofacial fractures. Using this system, a prospective sample of 324 patients with mandibular fractures presenting to the Royal Adelaide Hospital was coded for fracture severity and their progress followed with respect to complication rate. A strong correlation between complication rate and fracture severity was established.

Risk factors for infection following operative treatment of mandibular fractures: a multivariate analysis.

Utilizing a retrospective study design and a study sample of 284 consecutive patients, we measured the association between five different risk factors and the development of infection following the operative management of mandibular fractures. The five risk factors analyzed were age, sex, number of fractures per patient, time from admission to treatment, and treatment modality. The overall infection rate was 5.3 percent. The infection rate for each treatment modality was (1) 0 percent for closed reduction, (2) 20.0 percent for open reduction and internal fixation with wire osteosynthesis, and (3) 6.3 percent for open reduction and rigid internal fixation. To measure the association between the various risk factors and postoperative infection, we used multivariate logistic regression. After controlling for potential confounding variables, the only risk factor statistically associated with postoperative infection was treatment modality.

Relationship of substance abuse to complications with mandibular fractures

This retrospective study analyzed the relationship between complications and substance abuse following mandibular fracture. Over a 2-year period, the records of 352 patients with 589 mandibular fractures were reviewed for methods of treatment and other variables, including chronic abuse of drugs. An overall complication rate of 18.5% was found. Positive associations between complications and chronic abuse of alcohol and nonintravenous and intravenous drugs were found. Intravenous drug abusers had a 30%, nonintravenous drug abusers had a 19%, and chronic alcohol abusers had a 15.5% incidence of complications. Those individuals who did not use any drug chronically had a 6.2% complication rate. The results of this study show that chronic substance abuse can significantly affect treatment outcomes for management of mandibular fractures.

Extended access/internal approaches for the management of facial trauma.

The two most significant recent developments in the treatment of facial trauma are the introduction of plating systems, which provide rigid internal fixation and the development of surgical approaches that allow wide exposure of the entire facial skeleton while minimizing external incisions. These approaches (referred to as extended access/internal approaches) are hemicoronal and coronal flaps, the sublabial approach to the midface, the transconjunctival approach to the orbital floor and orbital rim, and the intraoral management of mandibular fractures. These approaches work well, and have become standard techniques for managing facial trauma; however, each one has definite technical points that need to be adhered to to assure their success. Additionally, there are situations where these approaches are not appropriate and, in fact, may even be detrimental. This article outlines our approach to facial trauma using these extended access/internal approaches and discusses the important technical factors of each approach. Our experience in treating 113 patients with 119 fractures and 161 approaches over the last 2 years is presented and the role extended access/internal approaches have played is reviewed. The indications, limitations, and possible complications associated with each approach are outlined.

Management of mandibular fractures in patients with endosseous implants

Seven patients who had previously received mandibular endosseous implants sustained mandibular fractures and were treated. Three patients had advanced bone resorption and developed stress fractures through previous endosseous implant sites. Two patients sustained fractures through implant sites via trauma. Two patients sustained fractures anatomically separated from the implants, which caused an alteration in the dental occlusion. This report describes the treatment approach for these seven patients and reviews the treatment philosophy and procedures involved. A conservative treatment approach is advised when the fracture transverses through a stable or a recently failed implant site.

Changing Concepts And Controversies In The Management Of Mandibular Fractures

The successful treatment of mandibular fractures and the avoidance of complications ultimately depends on sound surgical judgment. Judgments are influenced by an array of variables. Location, degree of complexity or displacement of the fracture, state of dentition, patient cooperativeness, presence of other maxillofacial trauma, and the surgeon's experience and expertise are some of these factors. We have attempted to outline the basic tenets of mandibular fracture management, recognizing that some areas remain controversial. It is hoped that as technology continues to improve, we will have the luxury of being more dogmatic about our approaches to these problems.

Plate and screw fixation in the management of mandible fractures

The use of compression plates and screws in the management of mandibular fractures is a reliable method of producing rigid internal fixation and a functionally stable fracture site. Early mandibular function is possible, resulting in a decrease in intermaxillary fixation time, improved oral hygiene and nutrition, and maintenance of normal neuromuscular physiology. Compression osteosynthesis results in primary bone healing, which has been shown to hasten osseous regeneration. With adherence to strict technical details and the use of sound clinical judgment, compression plate and screw techniques provide for a predictable method in the treatment of mandible fractures.

Evaluation of mini-plates in the management of mandibular fractures

Evaluation of mini-plates in the management of mandibular fractures

Plate and Screw Fixation in the Management of Mandible Fractures

The use of compression plates and screws in the management of mandibular fractures is a reliable method of producing rigid internal fixation and a functionally stable fracture site. Early mandibular function is possible, resulting in a decrease in intermaxillary fixation time, improved oral hygiene and nutrition, and maintenance of normal neuromuscular physiology. Compression osteosynthesis results in primary bone healing, which has been shown to hasten osseous regeneration. With adherence to strict technical details and the use of sound clinical judgment, compression plate and screw techniques provide for a predictable method in the treatment of mandible fractures.

Dynamic compression plating in treatment of the fractured, edentulous mandible.

The repair of a mandibular fracture in the edentulous patient can be a difficult surgical problem. A recent report of a large series of such cases by the University of Michigan disclosed a 20% rate of nonunion. Dynamic compression plating is particularly suited to the repair of fractures of the edentulous mandible as intermaxillary fixation is unnecessary, normal speech and diet are resumed immediately, and bone grafts can be used when necessary. This series of 36 plates used in the management of mandibular fractures in 24 edentulous patients is the largest series of its type reported thus far. No nonunion or other major complication occurred in this series. Because nonunion, delayed union, and the problems associated with intermaxillary fixation were avoided in this series, it is suggested that compression plating is a highly effective method for repair of fractured edentulous mandibles.

Intraosseous wire fixation versus rigid osseous fixation of mandibular fractures: A preliminary report

While wire osteosynthesis has been the accepted modality to use with open reduction of mandibular fractures, several authors have suggested the use of more rigid techniques to achieve the same result while also eliminating adverse effects associated with prolonged maxillomandibular fixation. Few studies have directly compared the two techniques in a prospective manner. The purpose of this paper was to evaluate complications seen with wire osteosynthesis versus a small bone plating system in management of mandibular fractures. The results suggest that small bone plating systems similar to the one used in this study may serve as a suitable alternative to wire osteosynthesis for the management of mandibular parasymphysis, body, and angle fractures. The length of the procedure, the length of hospital stay, and patient comfort were comparable with the two techniques. Factors that may contribute to failure are: location of the fracture, poor patient compliance, length of time from the trauma to the repair, antibiotic choice, and most importantly, operator skill and experience.

Management of mandibular fractures in the highlands of Papua New Guinea

The Management of fractured mandibles presenting in the Highlands of Papua New Guinea (PNG) is described and discussed. Features of management in this situation included: a longer period of prefixation conservative treatment; the elective use of local anaesthesia for all but the occasional operative procedure; a more aggressive attitude towards traumatised or infected teeth lying in fracture sites; confining all those patients in intermaxillary fixation or those receiving systemic medication to the hospital for the total duration of the treatment. Treatment was required to be compatible with the special problems of an unsophisticated patient population with delay in presentation, plus absence of adequate follow-up, with therapy being carried out in a hospital environment lacking specialist facilities.

Facial fractures: Hippocratic management.

Hippocrates, the famous Greek physician of the fifth century B.C., is considered to be the "Father of Medicine." Little, however, is known about his principles for the management of facial trauma. In this article, the Manuscripts in Ancient Greek, which deal with the management of mandibular fractures and dislocations, and with nasal and midfacial fractures have been translated and discussed. Hippocrates' methods for reducing mandibular dislocations and treating fractures of the mandible by wiring the teeth and immobilizing the jaw are described. His technique of closed reduction and immobilization of deviated nasal fractures with internal packing and rigid dorsal splints remains timeless. Hippocrates has taught us how to achieve medical wisdom through accurate clinical observation and practical creative ideas. The discovery of x-rays and antisepsis only furthered his established sound principles for the management of facial trauma.

Management of mandibular fractures with dynamic compression plates

Management of mandibular fractures with dynamic compression plates