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The management of unstable oblique infected mandibular fractures with a 2.3 mm mandibular osteosynthesis reconstruction bone plate
Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 600e605
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
The management of unstable oblique infected mandibular fractures with a 2.3 mm mandibular osteosynthesis reconstruction bone plate Walid A. Ghanem a, *, Khaled A. Elhayes b, Khalid Saad c a
Oral & Maxillofacial Surgery Department, Faculty of Dentistry, King Khaled University, Saudi Arabia Oral & Maxillofacial Surgery Department, Faculty of Dentistry, Cairo University, Egypt c Oral & Maxillofacial Surgery Department, Faculty of Dentistry, Tanta University, Egypt b
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 28 March 2009 Accepted 9 December 2010
This study is aimed to evaluate the efficacy of 2.3 mm reconstruction bone plates in the treatment of unstable infected mandibular fractures. Material: The study included 32 patients with unstable oblique infected mandibular fractures (23 males and 9 females), with a mean age of 33 years. The patients were divided into two groups. Group 1 were treated with an osteosynthesis plate (with at least 3 screws on each side of fracture sites) applied to the mandibular fracture site, while in group 2 the bone plate was applied (2 screws on each side of fracture sites) with maxillomandibular fixation (MMF). Clinical and radiographic examinations were carefully assessed preoperatively and postoperatively at follow-up intervals of 1, 2, 6, 12 months. Postoperative complications in terms of dysocclusion, wound dehiscence and neurosensory disturbances were examined. Result: Postoperative clinical and radiographic results showed that group 1 had quicker bone generation and more precise anatomical alignment of fracture sites than with those in group 2. All patients showed no evidence of infection, plate fracture or exposure, malunion, osteomyelitis, neurosensory disturbances, or dental injury. Conclusion: The 2.3 mm reconstruction bone plates provide excellent stability and healing of the unstable infected mandibular fractures provided that the fracture site is fixed by at least 3 screws on each side of the fracture sites. Ó 2010 European Association for Cranio-Maxillo-Facial Surgery.
Keywords: Unstable oblique infected mandibular fractures Mandibular osteosynthesis reconstruction bone plates 2.3 mm
1. Introduction Mandibular fractures are common facial injuries accounting for 36e59% of all maxillofacial fractures and their treatment is one of the most frequent forms of therapy provided by maxillofacial surgeons (Allan and Daly, 1990; Bochlogyros, 1985). Most of these fractures are solitary, but between 22% and 52% involve 2 or more sites in the mandible (Boole et al., 2001). For the surgeon who operates on patients presenting with facial trauma, fractures of the anterior mandible are common. Although there is a wide variance in the reported percentage of fractures of the anterior mandible, aggregate analysis places this at approximately 17% of all mandibular fractures (Bruce and Fonseca, 1991) while mandibular angle fractures make up 23e42% of all fractures in the mandible (Wittenberg et al., 1997). Traditionally, surgeons have
* Corresponding author. King Khaled Univ., Faculty of Dentistry, Abha, Saudi Arabia. Tel.: þ20 966542621817. E-mail address: [email protected] (W.A. Ghanem).
attempted to achieve four main goals when repairing the mandibular fractures: anatomical restitution, immobilization, prevention of infection and rehabilitation of function. Meeting these goals is essential for successful bone healing and correct postoperative function of the stomatognathic system (Peled et al., 1989). Techniques for the treatment of mandibular fractures have evolved significantly in the past decade. These techniques have ranged from closed reduction with maxillomandibular fixation (MMF), to open reduction with wire osteosynthesis, to open reduction with either rigid internal fixation or adaptive miniplate fixation (Dodson et al., 1990). Rigid fixation using compression plates has decreased the period of MMF and provided early return of mandibular function (Prein and Kellman, 1987). Transoral placement of noncompressive miniplate fixation has recently gained popularity using the principles of Champy et al. (1978). In recent years, new techniques using rigid internal fixation (plate osteosynthesis) for the treatment of mandibular fractures have been introduced (Anderson and Alpert, 1992). The basic concept of rigid fixation is absolute stability and there are a variety of techniques advocated to achieve this goal. Champy
1010-5182/$ e see front matter Ó 2010 European Association for Cranio-Maxillo-Facial Surgery. doi:10.1016/j.jcms.2010.12.002
W.A. Ghanem et al. / Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 600e605
et al. (1978) suggest that engaging a single cortex is sufficient for rigid osteosynthesis. In contrast, other authors believe that rigid osseous fixation is not obtained without bicortical engagement of the screws. A number of authors also report that compression has been principally achieved through a large compression system, less rigid mini-systems may suffice, however (Theirot et al., 1987). Prein and Kellman (1987) and Spiessl (1989) stressed two fundamental principles required to obtain adequate rigid internal fixation for comminuted mandibular fractures. First, the fixation needs to support the full functional loads (load-bearing osteosynthesis). Second, absolute stability of the fracture construct must be achieved. This is the prerequisite for sound bone healing and a low rate of infection. These principles can be applied to mandibular osteosynthesis reconstruction or universal plates. However, technically in comminuted fractures, the bone fragments cannot take part in the functional load, and therefore load-sharing osteosynthesis between implant and bone is not possible. The main advantage of bone plate osteosynthesis is that the patient does not need to undergo inter-maxillary fixation for weeks (Sauerbiers et al., 2008). The purpose of our study was to evaluate the efficacy of 2.3 mm mandibular osteosynthesis titanium reconstruction plates in the treatment of unfavorable unstable mandibular fractures. 2. Patients and methods Thirty-two patients were included in this study. There were 23 males and 9 females, ranging in age from 22 to 55 years (mean age 33 years). All these patients underwent placement of 2.3 mm mandibular osteosynthesis titanium reconstruction plates. Fracture distribution consisted of 20 angle fractures, 14 symphyseal fractures, and 16 parasymphyseal fractures (Table 1). Six sites showed bone loss associated with extraction of the involved teeth located in the fracture lines. Fractures were treated 4e6 days after the incidence of injury. On admission, all patients were placed on parenteral antibiotics (either cefazolin 1 g intravenously every 8 h or clindamycin 600 mg for penicillin-allergic patients 3 times per day intravenously) pain medication and chlorhexidine mouth rinse were prescribed. Preoperative clinical examination and dental occlusion were carefully evaluated, and panoramic X-ray film was done for each patient (Figs. 1 and 2). Preoperative maxillary and mandibular arch bars & maxillomandibular traction with heavy elastic rubber bands were applied under local anesthesia in most
Table 1 Mandibular reconstruction bone plate 2.3 mm. Patients
Fracture location
Fractures number
MMF period
Intra-oral approach
4 3 2 2 1 1 1 5 2 2 2 3 2 1 1 32
S S Left P/S RIGHT P/S RIGHT P/S Right angle Left angle Left angle/right Left angle/right Right angle/left Right angle/left Left angle/S Left angle/S Right angle/S Right angle/S
1 1 2 1 1 1 1 2 2 2 2 2 2 2 2 50
0 13 0 0 13 0 0 12 0 0 13 0 12 12 0 12.5
U U U
P/S P/S P/S P/S
Extra-oral approach
U U U U U U U U U U U U 22
10
Abbreviations: MMF, maxillomandibular fixation; P/S, parasymphysis; S, symphysis. Number of cases with bilateral fractures is 18. Number of cases with unilateral fractures is 14.
601
patients to reduce the displaced fragments and stabilize the mobile fragments. The patients were divided into two groups. In group 1 (18 patients) the patients underwent reduction in the mandibular fractures and fixation with 2.3 mm mandibular osteosynthesis titanium reconstruction plates (with at least 3 screws on each side of fracture sites). In group 2 (14 patients) the patients underwent reduction in the mandibular fractures and fixation with 2.3 mm mandibular osteosynthesis titanium reconstruction plates, (with 2 screws on each side of fracture sites) with maxillomandibular fixation (MMF). Some patients underwent extra-oral open reduction and placement of 2.3 mm mandibular osteosynthesis titanium reconstruction plates to fix the reduced mandibular fragments (Fig. 3). Intra-operative MMF was also applied in most cases to ensure optimal occlusion and to increase the stability of the reduced fragments. 2.1. Surgical technique The mandibular fractures were treated with open reduction under general anesthesia in the operating room. Teeth in the line of fracture were extracted only if they demonstrated mobility, tooth root fracture, apical pathology which was non-restorable, or interfered with the reduction of the fractures or occlusion. Intraoperative antibiotics were administered intravenously before making incisions. A 2.3-mm mandibular osteosynthesis titanium reconstruction plate was selected and then adapted to the lateral border of the external oblique ridge or the lateral aspect of the ramus for fixation of the reduced angle fracture, while for the parasymphyseal and symphyseal fractures, the plate was applied to the inferior border of the mandible. After adequate plate adaptation, the plates were secured with 2.3-mm screws with lengths ranging from 6 to 12 mm. At least 3 screws were placed on each side of the fracture sites for group 1 and 2 screws for group 2. After the screws were placed to secure the plate and the fracture(s) were adequately reduced, the inter-maxillary fixation was removed, and the occlusion checked for discrepancies and stability. Mucosal incisions were closed with chromic gut sutures in a running horizontal mattress fashion (Fig. 4). The patients in group 2, were placed into maximum inter-cuspation and inter-maxillary fixation with elastics for 2 weeks postoperatively. The mean period of the postoperative MMF was 12.5 days. No intra-oral/extra-oral drains were placed. Postoperative care included cefazolin 1 g intravenously every 8 h or clindamycin 600 mg for penicillin-allergic patients intravenously every 8 h, and pain medication as necessary. Patients were moved onto a full liquid diet as soon as possible and that was continued after discharge for 8 weeks. All patients were discharged from 1 to 3 days after surgery. On discharge patients were given oral antibiotics for 7 days and chlorhexidine mouth rinse was prescribed for 2 weeks after surgery. They were seen every 2 weeks until week 8, at which time their arch bars were removed (patients of group 2). The patients were followed and examined for postoperative complications in terms of dysocclusion, wound dehiscence, infection, new onset of neurosensory disturbances, damage to the teeth and adjacent structures, obvious scarring and malunion or nonunion of the fracture. The clinical and radiologic data from these patients were retrospectively analyzed at follow-up intervals of 1, 2, 6, 12 months. 3. Results Motor vehicular trauma was the leading mechanism of injury (60%), followed by aggravated assaults (35%), and falling from
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Fig. 1. (a) Preoperative photo shows patient with occlusal derangement. (b) Preoperative panoramic radiograph showing patient with bilateral mandibular fractures, right angle and left parasymphyseal fractures.
Fig. 2. (a) Preoperative photo shows patient with overriding the right parasymphyseal fracture segment. (b) Preoperative panoramic radiograph shows unilateral displaced right parasymphyseal fracture segment.
Fig. 3. Intra-operative photo shows extra-oral submandibular approach with good anatomical reduction and fixed with osteosynthesis plate 2.3 mm with 6 screws.
unknown cause (5%). Fractures included 32% parasymphysis fractures, 40% angle fractures, and 28% symphysis fractures. Eighty-five percent of the fractures were associated with a single tooth or multiple teeth in the line of the fracture, and
25% of these teeth were extracted at the time of open reduction. An extra-oral approach was used in 10 patients (31%), while 22 patients were treated (69%) via an intra-oral approach. Hypoaesthesia or anesthesia of the lower lip was observed in 1 patient (extra-oral approach for mandibular angle fracture) but was transient. None of the patients who underwent an extra-oral approach were dissatisfied with the scar or developed permanent facial nerve paresis. Postoperative radiographs showed that the patients in group 1 had a higher proportion of precise anatomical alignment of fractures than with those in group 2 (Fig 5). According to the clinical examination, all patients in both groups were recorded as having as satisfactory occlusion after surgery (Fig 6). No mobility was noted in any fracture site at the 8-week follow-up examination (Fig 7). Radiographic evaluation indicated a higher rate of bone formation of all fracture sites in group 1 compared to group 2 at 6 and 12 months follow-up visit (Fig. 8a, b). The majority of patients reported mild pain at the first postoperative visit with resolution by week 2. The operating time for the MMF group ranged from 60 to 130 min with an average of 95.5 min. For the non-MMF group, the operating times ranged from 35 to 55 min with an average of 45 min. The presence of teeth in the fracture line appears to make little difference to the operating time in both groups. No evidence of soft tissue infection, plate fracture or exposure, malunion, osteomyelitis, facial
W.A. Ghanem et al. / Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 600e605
603
Fig. 4. (a) Intra-operative photo shows reduction of mandibular angle fracture and fixation with a 2.3 mm osteosynthesis plate with 4 screws (intra-oral approach). (b) Intraoperative photo showing reduction of a mandibular parasymphyseal fracture and fixed with a 2.3 mm osteosynthesis plate with 4 screws (intra-oral approach).
Fig. 5. Postoperative panoramic radiograph shows satisfactory anatomical alignment of bilateral mandibular fracture, right angle and left parasymphyseal fractures.
nerve deficits, iatrogenic trigeminal nerve injury, or dental injury was noted. 4. Discussion Mandibular fractures are common facial injuries and are most frequently treated by oral and maxillofacial surgeons. The leading causes of mandibular fractures were motor vehicle accidents and assaults, and correspond with the findings of Allan and Daly (1990), and Bochlogyros (1985). Champy et al. (1978) and Cawood (1985) recommended that, to achieve the low rates of wound dehiscence and infection, miniplate osteosynthesis must be performed soon after injury. Champy et al. (1978) recommended fixation within 12 h, whereas Cawood (1985) extended this period to 24 h after injury. However Smith (1991) reported that the complication rates with delayed miniplate osteosynthesis were comparable with miniplate osteosynthesis performed within 24 h. This paper agreed with our study results, as the mandibular fractures were treated 4e6 days after the injury. Thus by careful management, including preoperative and postoperative oral hygiene with mouth washes and the use of antibiotics, complications with delayed miniplate osteosynthesis were largely overcome. The technique of placing a single miniplate at the upper border to fix fractures of the mandibular angle is based on the tension lines of the fracture distraction, as proposed by Michelet et al. (1973) and Champy et al. (1978). Studies have shown that of the different techniques used to fix fractures of the mandibular angle, the single miniplate at the upper border has the least morbidity, with the lowest number of complications (Levy et al., 1991). Fractures of the mandibular angle account for 23e42% of all mandibular fractures (Wald et al., 1988).
Due to the biomechanics of the mandible these fractures are associated with the highest incidence of post-surgical complications (Ardary, 1989). Ellis and Walker (1994) found an unacceptably high rate (28%) of complications of treatment using two non-compression miniplates. This suggests that there are not only biomechanical but also other important factors playing a role in the development of post-surgical complications, i.e., infection after rigid internal fixation of mandibular angle fractures. The disruption of the blood supply to the lateral mandible by stripping off the periosteum for fixation of miniplates at the inferior border may be one reason for the less favorable clinical results of two-plate fixation techniques. Two-plate fixation takes more time and longer operation time exposes the bone to a higher bacterial contamination. Percutaneous instrumentation for the application of a second miniplate may create hematomas, playing a role in post-surgical infection (Pushkar and Haitham, 2008). Successful bone healing is a delicate balance between sufficiently rigid internal fixation and the preservation of the bony and soft tissue environment required for fracture consolidation (Schierle et al., 1997). While Ayman et al. (2005) found fibrous nonunion as a postoperative complication in their study results, they reported that this complication was related to poor anatomical reduction and less than adequate bone to bone contact intra-operatively. This could have been prevented by the use of a load-bearing fixation device (DCP or reconstruction plate) rather than the load-sharing miniplate. More torsion movements are expected in the less rigid miniplates than the DCP or reconstruction plates, and therefore miniplates are not recommended for comminuted, unstable, and infected fractures (Levy et al., 1991). This is in agreement with our study results as the application of a 2.3 mm mandibular osteosynthesis bone plate provides good anatomical reduction with rigid internal fixation, less disruption of the blood supply to the lateral mandible and reduces the surface area of the periosteum to be stripped off for fixation with the osteosynthesis plate as we used only one plate for the mandibular fracture site. The time for application of the plate was shorter than that for two-plate fixation techniques. All patients in both groups were recorded as having a satisfactory occlusion after surgery. A similar finding was also reported by Fordyce et al. (1999) who followed their patients’ fractures up for 3 months post-surgery. The anterior mandible is not an area particularly prone to infection, but it is susceptible to malunion, and nonunion (Wagner and Neal, 1979). These complications were not seen in our study with
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Fig. 6. Photo (a) shows satisfactory occlusion 2 weeks postoperative. Photo (b) shows satisfactory alignment of mandibular 2 weeks postoperative.
Fig. 7. (a, b) Postoperative panoramic radiographs show after 8 weeks satisfactory fixation of mandibular fractures, with good bone formation.
either intra- or extra-oral approaches. As the 2.3 mm osteosynthesis plates were applied at the inferior border of the mandible below the apices of the teeth and mental foramen for fixation of symphyseal and parasymphyseal fractures so no nerve or dental injury was noted. The advantages of titanium plates for rigid fixation of mandibular fractures are that they allow the patient to have mandibular function and to achieve a normal diet earlier than those patients treated with closed reduction and a period of inter-maxillary fixation. This avoids hypomobility secondary to prolonged intermaxillary fixation (Gabriella et al., 2003). This agreed with our study results as no hypomobility was noted in all patients of group 1. Rigid fixation is believed to result in faster bone repair due to compression of the fracture segments and lack of mobility between the fracture segments (Kamboozia and Moorthy, 1993). This is in concordance with our study results as faster bone repair was seen in group 1 when compared to group 2 after 6 and 12 months postoperatively, especially if the plate is secured with at least 3 screws placed on each side of the fracture sites. No mobility was noted in any fracture site postoperatively or at the follow-up examinations of both groups.
5. Conclusion
Fig. 8. (a, b) Postoperative panoramic radiographs show higher rate of bone formation of all fractures sites in group 1 compared to group 2 after 12 months.
2.3 mm reconstruction bone plates provide excellent stability and healing of the unstable infected mandibular fractures provided that the fracture site is fixed by at least 3 screws on each side of fracture sites.
W.A. Ghanem et al. / Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 600e605
Sources of support No.
References Allan BP, Daly CC: Fractures of the mandible. A 35-year retrospective study. Int J Oral Maxillofac Surg 19: 268e271, 1990 Anderson T, Alpert B: Experience with rigid fixation of mandibular fractures and immediate function. Int J Oral Maxillofac Surg 50: 555e560, 1992 Ardary WC: Treatment of mandibular fractures. J Oral Maxillofac Surg 47: 1150e1153, 1989 Ayman C, Lazow Stewart K, Berger Julius R: Transoral 2.0-mm locking miniplate fixation of mandibular fractures plus 1 week of maxillomandibular fixation: a prospective study. J Oral Maxillofac Surg 63: 1737e1741, 2005 Bochlogyros PN: A retrospective study of 1521 mandibular fractures. J Oral Maxillofac Surg 43: 597e599, 1985 Boole JR, Holtel M, Amoroso P: 5196 Mandible fractures among 4381 active duty army soldiers, 1980 to 1998. Laryngoscope 111: 1691e1696, 2001 Bruce R, Fonseca RJ: Mandibular fractures. In: Fonseca W (ed.), Oral and maxillofacial trauma. Philadelphia: Saunders, 359e417, 1991 Cawood JI: Small plate osteosynthesis of mandibular fractures. Br J Oral Maxillofac Surg 23: 79e91, 1985 Champy M, Lodde JH, Must D: Mandibular osteosynthesis by miniature screwed plates via buccal approach. J Oral Maxillofac Surg 6: 14e21, 1978 Dodson TB, Perrot DH, Kaban LB, Gordon NC: Fixation of mandibular fractures: a comparative analysis of rigid internal fixation and standard fixation techniques. J Oral Maxillofac Surg 48: 362e366, 1990 Ellis E, Walker L: Treatment of mandibular fractures using two non-compression miniplates. J Oral Maxillofac Surg 52: 1032e1036, 1994 Fordyce AM, Lalani Z, Songra AK, Hildreth AJ, Carton ATM, Hawkesford JE: Intermaxillary fixation is not usually necessary to reduce mandibular fractures. Br J Oral Maxillofac Surg 37: 52e57, 1999
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Gabriella MA, Gabriella MF, Marcantonio E, Vieira HE: Fixation of mandibular fractures with 2.0-mm miniplates: review of 191 cases. J Oral Maxillofac Surg 61: 430e436, 2003 Kamboozia AH, Moorthy PA: The fate of teeth in mandibular fracture lines. A clinical and radiographic follow up study. Int J Oral Maxillofac Surg 22: 97e101, 1993 Levy FE, Smith RW, Odland RM, Marentette LJ: Monocortical miniplate fixation of mandibular angle fractures. Arch Otolaryngol Head Neck Surg 117: 149e154, 1991 Michelet FX, Deymes J, Dessus B: Osteosynthesis with miniaturized screwed plates in maxillofacial surgery. J Oral Maxillofac Surg 1: 79e84, 1973 Peled M, Laufer D, Helman J, Cutman D: Treatment of mandibular fractures by means of compression osteosynthesis. J Oral Maxillofac Surg 47: 566e569, 1989 Prein J, Kellman RM: Rigid internal fixation of mandibular fractures: basics of AO technique. Otolaryngol Clin North Am 20: 441e446, 1987 Pushkar M, Haitham M: Internal fixation of mandibular angle fractures: a compression of 2 techniques. J Oral Maxillofac Surg 66: 2254e2260, 2008 Sauerbier S, Schon R, Otten JE, Schmelzeisen R, Gutwald R: The development of plate osteosynthesis for the treatment of fractures of the mandibular body e A literature review. J Craniomaxillofac Surg 36: 251e259, 2008 Schierle HP, Schmelzeisen R, Rahn B, Pytlik C: One- or two-plate fixation of mandibular angle fractures? J Craniomaxillofac Surg 25: 162e168, 1997 Smith WP: Delayed miniplate osteosynthesis for mandibular fractures. Br J Oral Maxillofac Surg 29: 73e76, 1991 Spiessl B: Internal fixation of the mandible. Berlin-Heidelberg, Germany: SpringerVerlag, p. 23, 1989 Theirot BA, Van Sickels JE, Triplet RG, Nishioka GJ: Intraosseous wire fixation vs rigid osseous fixation of mandibular fractures: a preliminary report. J Oral Maxillofac Surg 45: 577e582, 1987 Wagner WF, Neal DC: Morbidity associated with extra oral open reduction of mandibular fractures. J Oral Surg 37: 97e102, 1979 Wald RM, Abemayor E, Zemplenyi J, Mannai M, Lesavoy A: The transoral treatment of mandibular fractures using noncompression miniplates: a prospective study. Ann Plast Surg 20: 409e413, 1988 Wittenberg JM, Mukherjee DP, Smith BR, Kruse RN: Biomechanical evaluation of new fixation devices for mandibular angle fractures. Int J Oral Maxillofac Surg 26: 68e73, 1997
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
The management of unstable oblique infected mandibular fractures with a 2.3 mm mandibular osteosynthesis reconstruction bone plate Walid A. Ghanem a, *, Khaled A. Elhayes b, Khalid Saad c a
Oral & Maxillofacial Surgery Department, Faculty of Dentistry, King Khaled University, Saudi Arabia Oral & Maxillofacial Surgery Department, Faculty of Dentistry, Cairo University, Egypt c Oral & Maxillofacial Surgery Department, Faculty of Dentistry, Tanta University, Egypt b
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 28 March 2009 Accepted 9 December 2010
This study is aimed to evaluate the efficacy of 2.3 mm reconstruction bone plates in the treatment of unstable infected mandibular fractures. Material: The study included 32 patients with unstable oblique infected mandibular fractures (23 males and 9 females), with a mean age of 33 years. The patients were divided into two groups. Group 1 were treated with an osteosynthesis plate (with at least 3 screws on each side of fracture sites) applied to the mandibular fracture site, while in group 2 the bone plate was applied (2 screws on each side of fracture sites) with maxillomandibular fixation (MMF). Clinical and radiographic examinations were carefully assessed preoperatively and postoperatively at follow-up intervals of 1, 2, 6, 12 months. Postoperative complications in terms of dysocclusion, wound dehiscence and neurosensory disturbances were examined. Result: Postoperative clinical and radiographic results showed that group 1 had quicker bone generation and more precise anatomical alignment of fracture sites than with those in group 2. All patients showed no evidence of infection, plate fracture or exposure, malunion, osteomyelitis, neurosensory disturbances, or dental injury. Conclusion: The 2.3 mm reconstruction bone plates provide excellent stability and healing of the unstable infected mandibular fractures provided that the fracture site is fixed by at least 3 screws on each side of the fracture sites. Ó 2010 European Association for Cranio-Maxillo-Facial Surgery.
Keywords: Unstable oblique infected mandibular fractures Mandibular osteosynthesis reconstruction bone plates 2.3 mm
1. Introduction Mandibular fractures are common facial injuries accounting for 36e59% of all maxillofacial fractures and their treatment is one of the most frequent forms of therapy provided by maxillofacial surgeons (Allan and Daly, 1990; Bochlogyros, 1985). Most of these fractures are solitary, but between 22% and 52% involve 2 or more sites in the mandible (Boole et al., 2001). For the surgeon who operates on patients presenting with facial trauma, fractures of the anterior mandible are common. Although there is a wide variance in the reported percentage of fractures of the anterior mandible, aggregate analysis places this at approximately 17% of all mandibular fractures (Bruce and Fonseca, 1991) while mandibular angle fractures make up 23e42% of all fractures in the mandible (Wittenberg et al., 1997). Traditionally, surgeons have
* Corresponding author. King Khaled Univ., Faculty of Dentistry, Abha, Saudi Arabia. Tel.: þ20 966542621817. E-mail address: [email protected] (W.A. Ghanem).
attempted to achieve four main goals when repairing the mandibular fractures: anatomical restitution, immobilization, prevention of infection and rehabilitation of function. Meeting these goals is essential for successful bone healing and correct postoperative function of the stomatognathic system (Peled et al., 1989). Techniques for the treatment of mandibular fractures have evolved significantly in the past decade. These techniques have ranged from closed reduction with maxillomandibular fixation (MMF), to open reduction with wire osteosynthesis, to open reduction with either rigid internal fixation or adaptive miniplate fixation (Dodson et al., 1990). Rigid fixation using compression plates has decreased the period of MMF and provided early return of mandibular function (Prein and Kellman, 1987). Transoral placement of noncompressive miniplate fixation has recently gained popularity using the principles of Champy et al. (1978). In recent years, new techniques using rigid internal fixation (plate osteosynthesis) for the treatment of mandibular fractures have been introduced (Anderson and Alpert, 1992). The basic concept of rigid fixation is absolute stability and there are a variety of techniques advocated to achieve this goal. Champy
1010-5182/$ e see front matter Ó 2010 European Association for Cranio-Maxillo-Facial Surgery. doi:10.1016/j.jcms.2010.12.002
W.A. Ghanem et al. / Journal of Cranio-Maxillo-Facial Surgery 39 (2011) 600e605
et al. (1978) suggest that engaging a single cortex is sufficient for rigid osteosynthesis. In contrast, other authors believe that rigid osseous fixation is not obtained without bicortical engagement of the screws. A number of authors also report that compression has been principally achieved through a large compression system, less rigid mini-systems may suffice, however (Theirot et al., 1987). Prein and Kellman (1987) and Spiessl (1989) stressed two fundamental principles required to obtain adequate rigid internal fixation for comminuted mandibular fractures. First, the fixation needs to support the full functional loads (load-bearing osteosynthesis). Second, absolute stability of the fracture construct must be achieved. This is the prerequisite for sound bone healing and a low rate of infection. These principles can be applied to mandibular osteosynthesis reconstruction or universal plates. However, technically in comminuted fractures, the bone fragments cannot take part in the functional load, and therefore load-sharing osteosynthesis between implant and bone is not possible. The main advantage of bone plate osteosynthesis is that the patient does not need to undergo inter-maxillary fixation for weeks (Sauerbiers et al., 2008). The purpose of our study was to evaluate the efficacy of 2.3 mm mandibular osteosynthesis titanium reconstruction plates in the treatment of unfavorable unstable mandibular fractures. 2. Patients and methods Thirty-two patients were included in this study. There were 23 males and 9 females, ranging in age from 22 to 55 years (mean age 33 years). All these patients underwent placement of 2.3 mm mandibular osteosynthesis titanium reconstruction plates. Fracture distribution consisted of 20 angle fractures, 14 symphyseal fractures, and 16 parasymphyseal fractures (Table 1). Six sites showed bone loss associated with extraction of the involved teeth located in the fracture lines. Fractures were treated 4e6 days after the incidence of injury. On admission, all patients were placed on parenteral antibiotics (either cefazolin 1 g intravenously every 8 h or clindamycin 600 mg for penicillin-allergic patients 3 times per day intravenously) pain medication and chlorhexidine mouth rinse were prescribed. Preoperative clinical examination and dental occlusion were carefully evaluated, and panoramic X-ray film was done for each patient (Figs. 1 and 2). Preoperative maxillary and mandibular arch bars & maxillomandibular traction with heavy elastic rubber bands were applied under local anesthesia in most
Table 1 Mandibular reconstruction bone plate 2.3 mm. Patients
Fracture location
Fractures number
MMF period
Intra-oral approach
4 3 2 2 1 1 1 5 2 2 2 3 2 1 1 32
S S Left P/S RIGHT P/S RIGHT P/S Right angle Left angle Left angle/right Left angle/right Right angle/left Right angle/left Left angle/S Left angle/S Right angle/S Right angle/S
1 1 2 1 1 1 1 2 2 2 2 2 2 2 2 50
0 13 0 0 13 0 0 12 0 0 13 0 12 12 0 12.5
U U U
P/S P/S P/S P/S
Extra-oral approach
U U U U U U U U U U U U 22
10
Abbreviations: MMF, maxillomandibular fixation; P/S, parasymphysis; S, symphysis. Number of cases with bilateral fractures is 18. Number of cases with unilateral fractures is 14.
601
patients to reduce the displaced fragments and stabilize the mobile fragments. The patients were divided into two groups. In group 1 (18 patients) the patients underwent reduction in the mandibular fractures and fixation with 2.3 mm mandibular osteosynthesis titanium reconstruction plates (with at least 3 screws on each side of fracture sites). In group 2 (14 patients) the patients underwent reduction in the mandibular fractures and fixation with 2.3 mm mandibular osteosynthesis titanium reconstruction plates, (with 2 screws on each side of fracture sites) with maxillomandibular fixation (MMF). Some patients underwent extra-oral open reduction and placement of 2.3 mm mandibular osteosynthesis titanium reconstruction plates to fix the reduced mandibular fragments (Fig. 3). Intra-operative MMF was also applied in most cases to ensure optimal occlusion and to increase the stability of the reduced fragments. 2.1. Surgical technique The mandibular fractures were treated with open reduction under general anesthesia in the operating room. Teeth in the line of fracture were extracted only if they demonstrated mobility, tooth root fracture, apical pathology which was non-restorable, or interfered with the reduction of the fractures or occlusion. Intraoperative antibiotics were administered intravenously before making incisions. A 2.3-mm mandibular osteosynthesis titanium reconstruction plate was selected and then adapted to the lateral border of the external oblique ridge or the lateral aspect of the ramus for fixation of the reduced angle fracture, while for the parasymphyseal and symphyseal fractures, the plate was applied to the inferior border of the mandible. After adequate plate adaptation, the plates were secured with 2.3-mm screws with lengths ranging from 6 to 12 mm. At least 3 screws were placed on each side of the fracture sites for group 1 and 2 screws for group 2. After the screws were placed to secure the plate and the fracture(s) were adequately reduced, the inter-maxillary fixation was removed, and the occlusion checked for discrepancies and stability. Mucosal incisions were closed with chromic gut sutures in a running horizontal mattress fashion (Fig. 4). The patients in group 2, were placed into maximum inter-cuspation and inter-maxillary fixation with elastics for 2 weeks postoperatively. The mean period of the postoperative MMF was 12.5 days. No intra-oral/extra-oral drains were placed. Postoperative care included cefazolin 1 g intravenously every 8 h or clindamycin 600 mg for penicillin-allergic patients intravenously every 8 h, and pain medication as necessary. Patients were moved onto a full liquid diet as soon as possible and that was continued after discharge for 8 weeks. All patients were discharged from 1 to 3 days after surgery. On discharge patients were given oral antibiotics for 7 days and chlorhexidine mouth rinse was prescribed for 2 weeks after surgery. They were seen every 2 weeks until week 8, at which time their arch bars were removed (patients of group 2). The patients were followed and examined for postoperative complications in terms of dysocclusion, wound dehiscence, infection, new onset of neurosensory disturbances, damage to the teeth and adjacent structures, obvious scarring and malunion or nonunion of the fracture. The clinical and radiologic data from these patients were retrospectively analyzed at follow-up intervals of 1, 2, 6, 12 months. 3. Results Motor vehicular trauma was the leading mechanism of injury (60%), followed by aggravated assaults (35%), and falling from
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Fig. 1. (a) Preoperative photo shows patient with occlusal derangement. (b) Preoperative panoramic radiograph showing patient with bilateral mandibular fractures, right angle and left parasymphyseal fractures.
Fig. 2. (a) Preoperative photo shows patient with overriding the right parasymphyseal fracture segment. (b) Preoperative panoramic radiograph shows unilateral displaced right parasymphyseal fracture segment.
Fig. 3. Intra-operative photo shows extra-oral submandibular approach with good anatomical reduction and fixed with osteosynthesis plate 2.3 mm with 6 screws.
unknown cause (5%). Fractures included 32% parasymphysis fractures, 40% angle fractures, and 28% symphysis fractures. Eighty-five percent of the fractures were associated with a single tooth or multiple teeth in the line of the fracture, and
25% of these teeth were extracted at the time of open reduction. An extra-oral approach was used in 10 patients (31%), while 22 patients were treated (69%) via an intra-oral approach. Hypoaesthesia or anesthesia of the lower lip was observed in 1 patient (extra-oral approach for mandibular angle fracture) but was transient. None of the patients who underwent an extra-oral approach were dissatisfied with the scar or developed permanent facial nerve paresis. Postoperative radiographs showed that the patients in group 1 had a higher proportion of precise anatomical alignment of fractures than with those in group 2 (Fig 5). According to the clinical examination, all patients in both groups were recorded as having as satisfactory occlusion after surgery (Fig 6). No mobility was noted in any fracture site at the 8-week follow-up examination (Fig 7). Radiographic evaluation indicated a higher rate of bone formation of all fracture sites in group 1 compared to group 2 at 6 and 12 months follow-up visit (Fig. 8a, b). The majority of patients reported mild pain at the first postoperative visit with resolution by week 2. The operating time for the MMF group ranged from 60 to 130 min with an average of 95.5 min. For the non-MMF group, the operating times ranged from 35 to 55 min with an average of 45 min. The presence of teeth in the fracture line appears to make little difference to the operating time in both groups. No evidence of soft tissue infection, plate fracture or exposure, malunion, osteomyelitis, facial
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Fig. 4. (a) Intra-operative photo shows reduction of mandibular angle fracture and fixation with a 2.3 mm osteosynthesis plate with 4 screws (intra-oral approach). (b) Intraoperative photo showing reduction of a mandibular parasymphyseal fracture and fixed with a 2.3 mm osteosynthesis plate with 4 screws (intra-oral approach).
Fig. 5. Postoperative panoramic radiograph shows satisfactory anatomical alignment of bilateral mandibular fracture, right angle and left parasymphyseal fractures.
nerve deficits, iatrogenic trigeminal nerve injury, or dental injury was noted. 4. Discussion Mandibular fractures are common facial injuries and are most frequently treated by oral and maxillofacial surgeons. The leading causes of mandibular fractures were motor vehicle accidents and assaults, and correspond with the findings of Allan and Daly (1990), and Bochlogyros (1985). Champy et al. (1978) and Cawood (1985) recommended that, to achieve the low rates of wound dehiscence and infection, miniplate osteosynthesis must be performed soon after injury. Champy et al. (1978) recommended fixation within 12 h, whereas Cawood (1985) extended this period to 24 h after injury. However Smith (1991) reported that the complication rates with delayed miniplate osteosynthesis were comparable with miniplate osteosynthesis performed within 24 h. This paper agreed with our study results, as the mandibular fractures were treated 4e6 days after the injury. Thus by careful management, including preoperative and postoperative oral hygiene with mouth washes and the use of antibiotics, complications with delayed miniplate osteosynthesis were largely overcome. The technique of placing a single miniplate at the upper border to fix fractures of the mandibular angle is based on the tension lines of the fracture distraction, as proposed by Michelet et al. (1973) and Champy et al. (1978). Studies have shown that of the different techniques used to fix fractures of the mandibular angle, the single miniplate at the upper border has the least morbidity, with the lowest number of complications (Levy et al., 1991). Fractures of the mandibular angle account for 23e42% of all mandibular fractures (Wald et al., 1988).
Due to the biomechanics of the mandible these fractures are associated with the highest incidence of post-surgical complications (Ardary, 1989). Ellis and Walker (1994) found an unacceptably high rate (28%) of complications of treatment using two non-compression miniplates. This suggests that there are not only biomechanical but also other important factors playing a role in the development of post-surgical complications, i.e., infection after rigid internal fixation of mandibular angle fractures. The disruption of the blood supply to the lateral mandible by stripping off the periosteum for fixation of miniplates at the inferior border may be one reason for the less favorable clinical results of two-plate fixation techniques. Two-plate fixation takes more time and longer operation time exposes the bone to a higher bacterial contamination. Percutaneous instrumentation for the application of a second miniplate may create hematomas, playing a role in post-surgical infection (Pushkar and Haitham, 2008). Successful bone healing is a delicate balance between sufficiently rigid internal fixation and the preservation of the bony and soft tissue environment required for fracture consolidation (Schierle et al., 1997). While Ayman et al. (2005) found fibrous nonunion as a postoperative complication in their study results, they reported that this complication was related to poor anatomical reduction and less than adequate bone to bone contact intra-operatively. This could have been prevented by the use of a load-bearing fixation device (DCP or reconstruction plate) rather than the load-sharing miniplate. More torsion movements are expected in the less rigid miniplates than the DCP or reconstruction plates, and therefore miniplates are not recommended for comminuted, unstable, and infected fractures (Levy et al., 1991). This is in agreement with our study results as the application of a 2.3 mm mandibular osteosynthesis bone plate provides good anatomical reduction with rigid internal fixation, less disruption of the blood supply to the lateral mandible and reduces the surface area of the periosteum to be stripped off for fixation with the osteosynthesis plate as we used only one plate for the mandibular fracture site. The time for application of the plate was shorter than that for two-plate fixation techniques. All patients in both groups were recorded as having a satisfactory occlusion after surgery. A similar finding was also reported by Fordyce et al. (1999) who followed their patients’ fractures up for 3 months post-surgery. The anterior mandible is not an area particularly prone to infection, but it is susceptible to malunion, and nonunion (Wagner and Neal, 1979). These complications were not seen in our study with
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Fig. 6. Photo (a) shows satisfactory occlusion 2 weeks postoperative. Photo (b) shows satisfactory alignment of mandibular 2 weeks postoperative.
Fig. 7. (a, b) Postoperative panoramic radiographs show after 8 weeks satisfactory fixation of mandibular fractures, with good bone formation.
either intra- or extra-oral approaches. As the 2.3 mm osteosynthesis plates were applied at the inferior border of the mandible below the apices of the teeth and mental foramen for fixation of symphyseal and parasymphyseal fractures so no nerve or dental injury was noted. The advantages of titanium plates for rigid fixation of mandibular fractures are that they allow the patient to have mandibular function and to achieve a normal diet earlier than those patients treated with closed reduction and a period of inter-maxillary fixation. This avoids hypomobility secondary to prolonged intermaxillary fixation (Gabriella et al., 2003). This agreed with our study results as no hypomobility was noted in all patients of group 1. Rigid fixation is believed to result in faster bone repair due to compression of the fracture segments and lack of mobility between the fracture segments (Kamboozia and Moorthy, 1993). This is in concordance with our study results as faster bone repair was seen in group 1 when compared to group 2 after 6 and 12 months postoperatively, especially if the plate is secured with at least 3 screws placed on each side of the fracture sites. No mobility was noted in any fracture site postoperatively or at the follow-up examinations of both groups.
5. Conclusion
Fig. 8. (a, b) Postoperative panoramic radiographs show higher rate of bone formation of all fractures sites in group 1 compared to group 2 after 12 months.
2.3 mm reconstruction bone plates provide excellent stability and healing of the unstable infected mandibular fractures provided that the fracture site is fixed by at least 3 screws on each side of fracture sites.
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Sources of support No.
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