OPEN REDUCTION AND INTERNAL FIXATION OF� COMBINED ANGLE AND BODY/SYMPHYSIS�FRACTURES OF THE MANDIBLE:� HOW MUCH FIXATION IS ENOUGH?

OPEN REDUCTION AND INTERNAL FIXATION OF� COMBINED ANGLE AND BODY/SYMPHYSIS�FRACTURES OF THE MANDIBLE:� HOW MUCH FIXATION IS ENOUGH? ellis article JOMS

1. OPEN REDUCTION AND INTERNAL FIXATION OF COMBINED ANGLE AND BODY/SYMPHYSIS FRACTURES OF THE MANDIBLE: HOW MUCH FIXATION IS ENOUGH? Edward Ellis III J Oral Maxillofacial Surgery 71:726-733, 2013

2. INTRODUCTION Bilateral fractures occur in over half of the patients who present with mandibular fractures. The most common mandibular fracture seen is an angle fracture combined with a contralateral fracture of the mandibular body or symphysis . T he management of mandibular fractures has changed from intermaxillary fixation (IMF ) with or without internal wire fixation to internal plate and/or screw fixation and no IMF. While the use of plate and/or screw fixation has potential benefits for the patient, complications are not uncommon.

3. Rigid internal fixation is a term applied to the application of sufficient internal hardware to prevent movement across the fracture site when normal functional forces are in effect. Examples of rigid internal fixation include locking/ nonlocking reconstruction bone plates, multiple bone plates at the fracture site, single strong non-reconstruction bone plates, or multiple lag screws. To prevent interfragmentary motion during function and allow primary osseous union to proceed. Rigid Fixation

4. Anything less than rigid is, by definition, nonrigid . Functionally stable fixation is not rigid fixation but is the application of various hardware schemes which do not prevent micro-motion across the fracture site during function, but permit healing of the fracture by secondary bone healing (with formation of callous) and without IMF . Examples :titanium miniplate for an angle fracture ( Champy technique) or a single titanium miniplate for body or symphysis fracture. Non -Rigid Fixation

5. AIM OF STUDY To assess the internal fixation requirements for combined mandibular angle and contralateral body or symphysis fracture of the mandible To examine a large sample of patients treated with rigid or non-rigid fixation for this common mandibular fracture.

6. PATIENTS AND METHODS

7. INCLUSION CRITERIA Age > 15 years . Simple (linear) fractures through the angle and the contralateral body or symphysis Neither fracture was grossly infected at time of treatment. Open reduction and internal fixation (ORIF) of the angle fracture through intraoral approach and application of a single 2 mm Titanium miniplate (1 mm thick) along the superior border ( Champy’s technique). ORIF of contralateral body or symphysis fracture through a transoral approach using a variety of plate and/or screw techniques. No postoperative IMF. 6-12 weeks of follow-up.

8. EXCLUSION CRITERIA Presence of gross infection of either fracture . Cases with insufficient records. Patient’s Irregular follow-ups.

9. DURATION : July 1, 1993 through December 31, 2012 GENERAL DEMOGRAPHIC INFORMATION : gender , age , cause , etc Location of angle fractures ( ie , left versus right ) Site of body or symphysis fracture. Presence of a tooth in the line of the fractures Extraction of tooth in line of fracture. Internal fixation techniques for the body or symphysis fracture. Occlusal relationship at last follow-up visit. Major postsurgical complications, which were defined as a need for further surgical intervention. Simple wound care ( prescriptions + antibiotics) Use of elastics for slight malocclusion was not considered as major complication.

10. RIGID GROUP At least two 2.4-mm lag screws with an arch bar. One 2.4-mm compression plate with an arch bar. Two 2-mm non-compression locking or non-locking mini-plates (1 mm thick ) with an arch bar. O ne 2-mm locking mandibular bone plate (all are thicker and much stronger than standard 1-mm-thick mini-plates) with or without a second plate and an arch bar. A non-locking 2.7-mm or locking 2.4-mm reconstruction bone plate with or without an arch bar.

11. 2 2.4mm LAG SCREWS 2.4-MM DYNAMIC COMPRESSION PLATE

12. TWO 2-mm MINIPLATES (1mm THICK) 2mm LOCKING PLATE

13. 2.4-MM RECONSTRUCTION BONE PLATE 2-mm LOCKING PLATE WITH A SMALLER , THINNER MINIPLATE PLACED ABOVE IT

14. NON-RIGID GROUP A SINGLE 2mm MINIPLATE (1-mm THICK) APPLIED TO BOTH FRACTURES

15. ANALYSIS The 2 groups were compared for differences in demographic characteristics using χ 2 cross-table analysis for discontinuous variables or Student t test for continuous variables . Outcomes for the 2 groups were similarly analyzed .

16. RESULTS

17. COMPLICATIONS

18. 36 12 TOTAL COMPLICATION = 48 (4.9%) 8 = WOUND PROBLEMS (dehiscence of the incision and exposure of the wound plate) 4 = INFECTIONS IN RIGID FIXATION

19. ALL WOUND PROBLEMS 36 19 = INFECTION (n=7) Abscess formation (n=8) Drainage of purulent matter intraorally (n=4) Drainage of purulent matter extraorally 19 underwent incision and drainage (n=13) I ntraoral approach (n=6) E xtraoral approach 15 = IMMEDIATE OR SUBSEQUENT HARDWARE REMOVAL 4 = no bony union 1 = bone grafting required after 4 months

20. ALL WOUND PROBLEMS 36 17 = NON-INFECTED WOUND PROBLEMS granulation tissue around the incision site plate /bone exposure 7 = loose hardware 4 = fracture not united

21. TOTAL COMPLICATION = 23 (15.4%) 22 = WOUND PROBLEMS 8 = Angle fracture site 2 = Body site 4 = B oth sites IN NON-RIGID FIXATION 14 = NON-INFECTED WOUND PROBLEMS granulation tissue around the incision site plate /bone exposure 9 = loose hardware

22. TOTAL COMPLICATION = 23 (15.4%) IN NON-RIGID FIXATION IMMEDIATE OR SUBSEQUENT HARDWARE / NON VITAL BONE REMOVAL (transoral approach) 8 = fracture has healed 6 = mobility present 8 = INFECTION (n=4) Abscess formation without drainage (n=5) Drainage of purulent matter through incision site 7 ANGLE 1 BODY 7 = Hardware removal 3 = Mobility

23. MALOCCLUSION 1 CASE OF MALOCCLUSION REQUIRED SECONDARY INTERVENTION AFTER 4 WEEKS POST OPERATIVELY IN-LINE DEFORMATION OF BONE PLATE APPLIED TO BODY/ SYMPHYSIS REGION

24. DISCUSSION

25. Studies have reported that when treating mandibular fractures , rigid fixation is not always necessary, and there are multiple functionally stable hardware constructs that result in healing and excellent postoperative results . S tatistically significant difference in the major complication rate between the rigid and nonrigid groups (P < .001 ). The results of this study show a significantly higher rate of wound problems when both fractures are treated with nonrigid fixation. This indicates that although nonrigid forms of fixation may work on isolated (single ) fractures of the mandible, they might not be reliable when used on more than one fracture of the mandible.

26. Condylar process and Angle fixation

27. Combined Contralateral Angle and Body Combined Contralateral Angle and symphysis

28. PITFALLS Only simple linear # were included Relationship with # pattern were not studied The word slight malocclusion was not defined Rigid group 976; nonrigid group 149 Very small sample size of non rigid group HIGHLIGHTS Large study population First article of its kind

29. CONCLUSION The fixation requirements of patients treated with double fractures of the mandible are different than when treating isolated fractures of the mandible. Double fractures require that at least one of the fractures undergoes rigid fixation to decrease the incidence of complications.