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Surgical treatment of fractures of the edentulous mandible
1087
BRIAN ALPERT 4. Obwegeser HL, Sailer HF: Another way of treating fractures of the atrophic edentulous mandible. J Maxillofac Surg 1:213, 1973 5. l?zsi& A, Sugar AW: Pathological fractures of the mandible: A diagnostic and treatment dilemma. Br .I Oral Maxillofac Surg 32:303, 6.
1994
Cawood JI, Howell RA: Reconstructive preprosthetic surgery. I. Anatomical considerations. Int .I Oral Maxillofac Surg 20:75, 1991
Farmand M, Ryffel M: Results after mandibular ridge augmentation with laminated split ribs, pedicled anterior bone lid and simultaneous sulcoplasties. J Craniomaxillofac Surg 15: 141, 1987 8. Gr& KW, Sailer HF, Oechslin CK: Results after interforaminal mandibular sandwich procedure in combination with titanium screw implants. Oral Maxillofac Surg Clin North Am 6:689, 1994 9. Merten H-A, Wiese KG: Frakturen des zahnlosen, atrophischen Unterkiefers. Dtsch Z Mund Kiefer Gesichts Chir 16:144, 1992 10. Freihofer HP, Sailer HF: Experiences with intraoral trans-osseous wiring of mandibular fractures. J Maxillofac Surg 1:248, 1973 7.
11. Thaller SR: Fractures of the edentulous mandible: A retrospective review. J Craniofac Surg 4:91, 1993 12. Bruce RA, Ellis E III: The Second Chalmers J. Lyons Academy Study of Fractures of the Edentulous Mandible. J Oral Maxillofac Surg 51:904, 1993 13. Sailer HF: Therapiekonzepte der spontanen Unterkieferfrakturen. Dtsch zahntiztl Z 38:426, 1983 14. Thoma KH: Progressive atrophy of the mandible complicated by fractures: Its reconstruction. Oral Surg 13:4, 1960 15. Sailer HF: Neue Methoden zur oralen Rehabilitation. Swiss Dent 10:23, 1991 16. Bruce RA, Strachnan DS: Fractures of the edentulous mandible: The Chambres Lyons Academy study. J Oral Surg 34:973, 1976 17. Levine P: Treatment of fractures of the edentulous mandible. Arch Otolaryngol 108:167, 1982 18. Amartunga NA de SA: Comparative study of the clinical aspects of edentulous and dentulous mandibular fractures. Oral Surg Oral Med Oral Path01 46:3, 1988 19. Newman L: The role of autogenous primary rib grafts in treating fractures of the atrophic edentulous mandible. Br J Oral Maxillofac Surg 33:381, 1995
J Oral Maxillofac Surg 55:1087-1088, 1997
Discussion Surgical
Treatment of Fractures Edentulous Mandible
of the
Brian Alpert, DDS University
of Louisville,
Kentucky
Treatment of atrophic mandibular fractures can certainly be challenging. Elderly, infirm patients, unopposed muscle pull, diminished blood supply, bone inadequate qualitatively and quantitatively for osteosynthesis, and inadequate ridges for stable splints or prostheses all lead to treatment that is difficult and prone to failure. Over the years, treatment has run the gamut from skillful neglect (still a good choice in minimally displaced, usually unilateral fractures) to splints for monomaxillary or maxillomandibular fixation (MMF),’ skeletal pin fixation,’ and open reduction and internal fixation (ORIF) with wire,3 mesh,4 split ribs,’ Steinman pins,6 miniplates, compression plates,’ and reconstruction plates.’ Often, ORIF was done in addition to, rather than in place of, splinting techniques.” Both tradition and the literature have favored closed techniques as initial treatment.“,” However, all too often, closed reduction has failed, followed by ORIF using wire or miniplates that failed, followed by more rigid fixation with a bone graft that might be successful. I have done them all (often poorly) and have come to the following conclusions regarding the treatment of edentulous mandible fractures: 1. Elderly, infirm people do not tolerate MMF very well. They tend to die. It is better to do nothing. 2. Dentures or splints retained with wire or screws are uncomfortable, unstable, prone to infection, and should be abandoned.
3. Do what you know will work, not what you hope will work. 4. Skeletal pin fixation (external fixators) work well but are ungainly and should be replaced by properly conceived and applied rigid internal fixation. It is still useful when the patient needs an extensive open operation but cannot tolerate it. 5. ORIF with wire or miniplate fixation is prone to failure in atrophic mandibular fractures. 6. Use a reconstruction plate that is firmly anchored with bicortical screws placed well away from the fracture (often angle and symphysis). This becomes an internal fixator. The patient is functional while healing (or complications) take place. 7. Primarily graft atrophic fracture sites (as well as potential implant sites) with autogenous particulate marrow. (The tibia is an appropriate site with minimal morbidity). With trne rigid fixation, there is no callus formation to bridge gaps. 8. The transoral approach is preferred (although the literature does not support it).” 9. Complete the rehabilitation and prevent further atrophy with implant restoration. This grows bone with time and function.
References 1. Eric JB: Treatment of bilateral fractures of the edentulous mandible. Plast Reconstr Surg 9:33, 1952 2. Morris JH: Biphase connector, external skeletal splint for reduction and fixation of mandibular fractures. Oral Surg Oral Med Oral Path01 2:1382, 1949
1088 3. Dingman RO, Natvig P: Surgery of Facial Fractures. Philadelphia, PA, Saunders, 1964, pp 162-168 4. Hahn GW, Cargill DA: Mandibular fracture fixation with malleable metal mesh. J Oral Surg 27:180, 1969 5. Obwegeser HL, Sailer HF: Another way of treating fractures of the atrophic edentulous mandible. J Maxillofac Surg 1:213, 1973 6. Bisi RH: The management of mandibular fractures in edentulous patients by intramedullary pinning. Laryngoscope 83:22, 1973 7. Davies BW, Cederna JP, Guyuron B: Non-compression unicortical miniplate osteosynthesis of mandibular fractures. Ann Plast Surg 28:414, 1992
DISCUSSION 8. Luhr H, Reidick T, Merten H: Results of treatment of fracture of the atrophic edentulous mandible by compression plating. J Oral Maxillofac Surg 54:250, 1996 9. Speissl B: Internal fixation of the mandible. New York, NY, Springer-Verlag, 1989, pp 223-227 10. Bruce RA, Ellis E: The second Chalmers T. Lyons Academy study of fractures of the edentulous mandible. J Oral Maxillofat Surg 51:904, 1993 11. Marciani RD, Hill OJ: Treatment of the fractured edentulous mandible. J Oral Surg 37569, 1979 12. Bruce RA, Strachan DS: Fractures of the edentulous mandible: The Chalmers Lyon Academy study. J Oral Surg 34:973, 1976
BRIAN ALPERT 4. Obwegeser HL, Sailer HF: Another way of treating fractures of the atrophic edentulous mandible. J Maxillofac Surg 1:213, 1973 5. l?zsi& A, Sugar AW: Pathological fractures of the mandible: A diagnostic and treatment dilemma. Br .I Oral Maxillofac Surg 32:303, 6.
1994
Cawood JI, Howell RA: Reconstructive preprosthetic surgery. I. Anatomical considerations. Int .I Oral Maxillofac Surg 20:75, 1991
Farmand M, Ryffel M: Results after mandibular ridge augmentation with laminated split ribs, pedicled anterior bone lid and simultaneous sulcoplasties. J Craniomaxillofac Surg 15: 141, 1987 8. Gr& KW, Sailer HF, Oechslin CK: Results after interforaminal mandibular sandwich procedure in combination with titanium screw implants. Oral Maxillofac Surg Clin North Am 6:689, 1994 9. Merten H-A, Wiese KG: Frakturen des zahnlosen, atrophischen Unterkiefers. Dtsch Z Mund Kiefer Gesichts Chir 16:144, 1992 10. Freihofer HP, Sailer HF: Experiences with intraoral trans-osseous wiring of mandibular fractures. J Maxillofac Surg 1:248, 1973 7.
11. Thaller SR: Fractures of the edentulous mandible: A retrospective review. J Craniofac Surg 4:91, 1993 12. Bruce RA, Ellis E III: The Second Chalmers J. Lyons Academy Study of Fractures of the Edentulous Mandible. J Oral Maxillofac Surg 51:904, 1993 13. Sailer HF: Therapiekonzepte der spontanen Unterkieferfrakturen. Dtsch zahntiztl Z 38:426, 1983 14. Thoma KH: Progressive atrophy of the mandible complicated by fractures: Its reconstruction. Oral Surg 13:4, 1960 15. Sailer HF: Neue Methoden zur oralen Rehabilitation. Swiss Dent 10:23, 1991 16. Bruce RA, Strachnan DS: Fractures of the edentulous mandible: The Chambres Lyons Academy study. J Oral Surg 34:973, 1976 17. Levine P: Treatment of fractures of the edentulous mandible. Arch Otolaryngol 108:167, 1982 18. Amartunga NA de SA: Comparative study of the clinical aspects of edentulous and dentulous mandibular fractures. Oral Surg Oral Med Oral Path01 46:3, 1988 19. Newman L: The role of autogenous primary rib grafts in treating fractures of the atrophic edentulous mandible. Br J Oral Maxillofac Surg 33:381, 1995
J Oral Maxillofac Surg 55:1087-1088, 1997
Discussion Surgical
Treatment of Fractures Edentulous Mandible
of the
Brian Alpert, DDS University
of Louisville,
Kentucky
Treatment of atrophic mandibular fractures can certainly be challenging. Elderly, infirm patients, unopposed muscle pull, diminished blood supply, bone inadequate qualitatively and quantitatively for osteosynthesis, and inadequate ridges for stable splints or prostheses all lead to treatment that is difficult and prone to failure. Over the years, treatment has run the gamut from skillful neglect (still a good choice in minimally displaced, usually unilateral fractures) to splints for monomaxillary or maxillomandibular fixation (MMF),’ skeletal pin fixation,’ and open reduction and internal fixation (ORIF) with wire,3 mesh,4 split ribs,’ Steinman pins,6 miniplates, compression plates,’ and reconstruction plates.’ Often, ORIF was done in addition to, rather than in place of, splinting techniques.” Both tradition and the literature have favored closed techniques as initial treatment.“,” However, all too often, closed reduction has failed, followed by ORIF using wire or miniplates that failed, followed by more rigid fixation with a bone graft that might be successful. I have done them all (often poorly) and have come to the following conclusions regarding the treatment of edentulous mandible fractures: 1. Elderly, infirm people do not tolerate MMF very well. They tend to die. It is better to do nothing. 2. Dentures or splints retained with wire or screws are uncomfortable, unstable, prone to infection, and should be abandoned.
3. Do what you know will work, not what you hope will work. 4. Skeletal pin fixation (external fixators) work well but are ungainly and should be replaced by properly conceived and applied rigid internal fixation. It is still useful when the patient needs an extensive open operation but cannot tolerate it. 5. ORIF with wire or miniplate fixation is prone to failure in atrophic mandibular fractures. 6. Use a reconstruction plate that is firmly anchored with bicortical screws placed well away from the fracture (often angle and symphysis). This becomes an internal fixator. The patient is functional while healing (or complications) take place. 7. Primarily graft atrophic fracture sites (as well as potential implant sites) with autogenous particulate marrow. (The tibia is an appropriate site with minimal morbidity). With trne rigid fixation, there is no callus formation to bridge gaps. 8. The transoral approach is preferred (although the literature does not support it).” 9. Complete the rehabilitation and prevent further atrophy with implant restoration. This grows bone with time and function.
References 1. Eric JB: Treatment of bilateral fractures of the edentulous mandible. Plast Reconstr Surg 9:33, 1952 2. Morris JH: Biphase connector, external skeletal splint for reduction and fixation of mandibular fractures. Oral Surg Oral Med Oral Path01 2:1382, 1949
1088 3. Dingman RO, Natvig P: Surgery of Facial Fractures. Philadelphia, PA, Saunders, 1964, pp 162-168 4. Hahn GW, Cargill DA: Mandibular fracture fixation with malleable metal mesh. J Oral Surg 27:180, 1969 5. Obwegeser HL, Sailer HF: Another way of treating fractures of the atrophic edentulous mandible. J Maxillofac Surg 1:213, 1973 6. Bisi RH: The management of mandibular fractures in edentulous patients by intramedullary pinning. Laryngoscope 83:22, 1973 7. Davies BW, Cederna JP, Guyuron B: Non-compression unicortical miniplate osteosynthesis of mandibular fractures. Ann Plast Surg 28:414, 1992
DISCUSSION 8. Luhr H, Reidick T, Merten H: Results of treatment of fracture of the atrophic edentulous mandible by compression plating. J Oral Maxillofac Surg 54:250, 1996 9. Speissl B: Internal fixation of the mandible. New York, NY, Springer-Verlag, 1989, pp 223-227 10. Bruce RA, Ellis E: The second Chalmers T. Lyons Academy study of fractures of the edentulous mandible. J Oral Maxillofat Surg 51:904, 1993 11. Marciani RD, Hill OJ: Treatment of the fractured edentulous mandible. J Oral Surg 37569, 1979 12. Bruce RA, Strachan DS: Fractures of the edentulous mandible: The Chalmers Lyon Academy study. J Oral Surg 34:973, 1976