Professional Documents
Culture Documents
1999; 28:243~52
Printed flz Denmark. All rights reserved
Oral8r
Maxill@cial Surgery
ISSN 090t-5027
Leading article
E d w a r d Ellis III
Oral and Maxillofacial Surgery, The University
of Texas Southwestern Medical Center,
Dallas, Texas, USA
E. Ellis III. Treatment methods for fractures of the mandibular angle. Int. J. Oral
Maxillofac. Surg. 1999, 28." 243~52. 9 Munksgaard, 1999
Abstract. Fractures of the mandibular angle are plagued with the highest rate of
complication of all mandibular fractures. Over the past 10 years, various forms
of treatment for these fractures were performed on an indigent inner city
population. Treatment included: 1) closed reduction or intraoral open reduction
and non-rigid fixation; 2) extraoral open reduction and internal fixation with an
AO/ASIF reconstruction bone plate; 3) intraoral open reduction and internal
fixation using a solitary lag screw; 4) intraoral open reduction and internal
fixation using two 2.0 mm mini-dynamic compression plates; 5) intraoral open
reduction and internal fixation using two 2.4 mm mandibular dynamic
compression plates; 6) intraoral open reduction and internal fixation using two
non-compression miniplates; 7) intraoral open reduction and internal fixation
using a single non-compression miniplate; and 8) intraoral open reduction and
internal fixation using a single malleable non-compression miniplate. This paper
reviews the results of those modes of treatment when used for the same patient
population at one hospital. Results of treatment show that, in this patient
population, the use of either an extraoral open reduction and internal fixation
with the AO/ASIF reconstruction plate or intraoral open reduction and internal
fixation, using a single miniplate, are associated with the fewest complications.
Fractures of the mandibular angle represent the largest percentage of mandibular fractures in many studies. The
etiology of the injury has something to
do with the location of the mandible
that fractures. Fractures sustained in
altercations show a high incidence of
fractures of the angle of the mandible 33'4~176
The prevailing
thought is that a blow to the lateral
portion of the mandible causes a fracture at that point, and commonly a
fracture on the opposite body/symphysis region.
Why is the angle of the mandible
commonly associated with fractures?
There are several proposed reasons that
include: 1) the presence of third molars;
2) a thinner cross-sectional area than
the tooth-bearing region; and 3) bio-
quired when no tooth was present, Clinical investigations have shown that patients with third molars present are
more likely to sustain fractures of the
angle than when no tooth is present s6,7~ Further, the amount of space
occupied by the third molar was found
to directly relate to weakness in that region of the mandible 56,
One would logically expect fractures
to occur at points of greatest weakness
in a structure. One would also logically
expect that thinner cross-sectional areas
of a structure would be weaker than
those areas with greater cross-sectional
areas. A study by SHVBERT et al. 63 has
shown that the region of the mandibular angle is thinner than both the bone
of the body region located more anteriorly, and the bone of the ramus located
244
Ellis
245
Fig. 1. Immediate postoperative radiograph showing angle fracture treated with transosseous
wire fixation and intermaxillary fixation. Wire was inserted through the buccal cortex of the
extraction socket.
"gold standard"
closed reduction or open
reduction using non-rigid fixation has been
used for centuries and constitutes such a
group. A retrospective study was performed
to gain an appreciation for the complication
rate of traditional treatment of angle fractures in our patient population 49.
The records of patients treated by non-rigid means of fixation for mandibular angle
fractures in a 3-year period were evaluated
retrospectively. Treatment of the fractures
was by closed reduction and/or open reduction with non-rigid means of interosseous
fixation such as transosseous wires, circummandibular wires or small positional bone
plates (Fig. 1). Postsurgical I M F was prescribed for six weeks in all patients.
During the 3-year period, 96 patients with
99 fractures through the mandibular angle
(three were bilateral) had charts available
with sufficient information for inclusion in
this studY. Of the 99 fractures, 59 were
treated with closed reduction (59%), 34 with
open reduction and placement of a transosseous wire (34"/0), five with open reduction
and a positional bone plate, and one fracture
was treated by closed reduction with the addition of a circummandibular wire (1%). All
patients were placed into postsurgical I M F
for an average of 40 days (range 20 -80 days).
Follow-up ranged from 21 252 days with an
average of 75 days.
Complications developed in 17 fractures
(17%), of which there were 13 with infections
and four cases where infection was combined
with malunion and malocclusion. There were
no cases of non-union. The time between initial presentation and surgery in these patients
was similar to the overall group of patients.
All patients underwent incision and drainage
procedures for their infections. Nine patients
were hospitalized at least once for their infection and/or malocclusion/malunion. During
the incision and drainage procedures, four
patients underwent removal of osteosynthesis; two had teeth in the line of fracture extracted; three patients whose initial treatment
was closed reduction had transosseous wires
The AO reconstruction bone plate is a reinforced plate that is thicker and stronger
than the standard AO/ASIF compression
bone plate. It comes in various lengths and
the plate is three-dimensionally bendable,
allowing accurate contouring to the surface
of the mandible. The use of three screws on
each side of the fracture with this bone pIate
is claimed to provide adequate neutralization
of functional forces in the absence of coinpression 6~ it is useful in areas of comminution, bone loss or obliquity where one cannot use standard compression bone plates.
The records of all patients with unilateral
fractures of the mandibular angle treated
with a reconstruction bone plate over a 3year period were collected. The technique for
application of the plate has been published
elsewhere and consisted of an extraoral approach in most instances (Fig. 2) 21.
The records of fifty-two patients with unilateral angle fractures treated in the 3-year
period, who had adequate follow-up information in their chart, were available for review. The fractures were categorized as being
comminuted in 31 cases, oblique in 12 and
simple linear fractures in 9. Following application of the bone plate,' all fractures appeared to be well reduced and stable. All
dentulous patients had a reproducible occlusion in the operating room. Four patients
had pre-existent infections of the fracture
246
El/is
One AO/ASIF method to neutralize the functional forces of an angle fracture is by restor-
Because of the high rate of postsurgical complications in patients treated with two 2.0
mm mini-dynamic compression plates, it was
decided to study the standard AO/ASIF technique for treating fractures of the mandibular angle by the application of two com-
247
The AO/ASIF recommendation for application of two compression bone plates for
angle fractures was found to result in very
high rates of complication in our patient
population 2~
Because large bony sequestra were frequently encountered in these
patients, we thought that a reason for the
high rate of postoperative infection was devi-
Because of the high rates of complication resulting when two bone plates were placed, it
was decided to attempt the use of a single
2.0 mm plate
1.3 mm plate
0.9
0.007
0.158
0.14
0.93
0.5
0.001
0.029
0.04
0.40
248
Ellis
Fig. 8. Photograph of standard 2.0 m m miniplate and 1.3 m m miniplate used in this investigation (A). 1.3 m m plate is extremely thin
and malleable as shown in this photograph (B).
Fig. 9. Immediate postoperative radiograph showing angle fracture treated with single 1.3 m m
non-compression plate.
249
Study Reference
Non-rigid fixation
AO reconstruction plate (2.7 mm)
Solitary lag screw
Two mini-dynamic compression plates (2.0 mm)
Two mandibular dynamic compression plates (2.4 ram)
Two non-compression miniplates (2.0 mm)
One non-compression miniplate (2.0 ram)
One malleable non-compr miniplate (1.3 mm)
Major Complication~
99
52
88
30
65
67
81
51
17%
7.5%
13%
13%
32%
23%
2.5%
0%
Discussion
At the beginning of these investigations, we never would have considered using a single miniplate to adequately stabilize a fracture of the angle
of the mandible without supplemental
IME Ten years ago, indoctrinated by
the AO/ASIF teaching that absolute rigid fixation was necessary, stable
methods were deemed necessary and
were used in this patient population.
Reconstruction plates, lag screws, and
two-plate systems were implemented
with the thought that they were absolutely stable methods. However, other
than the reconstruction plate, the intraoral techniques of stable fixation proved
either unstable in a certain percentage
of cases (solitary lag screw) or fraught
with high rates of major postsurgical
complications (two plates).
The results of these consecutive
series of clinical investigations performed in our hospital on a similar patient population indicate that, contrary
to popular beliefs, up to a point, the incidence of major complications after
fractures of the mandibular angle are
inversely proportional to the rigidity of
the fixation applied. Whenever two
points of fixation were used for fractures of the angle, the complication rate
was much higher than when one point
of fixation was applied. That is not to
say that using a single miniplate does
not result in complications. However,
the vast majority of problems that arose
in patients treated by a single miniplate,
such as wound dehiscence, wound infections, plate exposure etc., were easily
treated in the outpatient clinic under local anesthesia. Even removal of the
bone plate after healing of the fracture,
when necessary, is a simple procedure in
the outpatient setting. However, when a
second plate was applied at the inferior
border, the complications tended to be
more severe, with large areas of nonvital
bone, sequestra formation and need for
plate removal, which were difficult to
250
Ellis
much better than double plating systems. SHIERLE et al. 58 compared a single
miniplate to the use of two and found
no significant difference in results. The
results of our studies and the one by
SCHIRLE et al. 58 indicate that biomechanics are only one factor to be
considered when treating fractures.
There are many others that may be
more important. Perhaps improved
maintenance of the blood supply to the
bone because of limited dissection is
one such factor s 7,17,32. We, therefore,
agree with EWERS & HARLE 26'27 who
questioned the need for absolute rigidity for treatment of fractures. F r o m the
foregoing, it is obvious that fractures of
the mandibular angle do not require the
amount of stability as determined in
biomechanical tests. This should not be
surprising in light of bite force studies
by GERLACH et al. 3~ and TATE et al. 69
which showed that bite forces are subnormal for many weeks after fracture of
the mandible.
W h a t has yet to be determined is
exactly what are the requirements for
fixation of angle fractures. Based upon
the results of using a malleable 1.3 m m
plating system, this plate should not be
routinely used for such fractures because some fractured during function.
However, the fact that most did not
fracture indicates that the 2.0 m m miniplates are probably over-engineered for
this task. Perhaps a thinned down version of the 2.0 mm miniplate system
will prove even simpler to apply and adequately stable without plate fracture.
Another alternative might be to thicken
the 1.3 m m plate. These results also indicate that biodegradable fixation systems, which do not have the same
strength as metallic plates of the same
dimension, may provide adequate fixation in this region.
There have been studies on the treatment of fractures of the mandible that
have shown that operator experience is
an important factor in treatment results 3'34'37. There is no question that experienced surgeons can treat injuries
faster and perhaps with less surgical
trauma that those who are less experienced. Because the techniques that
proved most beneficial were those completed latest in this 10-year experience,
one might argue that the improved results are not due to treatment methods
but instead due to operator experience,
which one would presume to increase
over time. There is one factor that refutes this supposition, however. A var-
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Address:
Edward Ellis 11I, D.D.S., M.S.
Professor, Oral and Maxillofacial Surgery
The University of Texas Southwestern
Medical Center
5323 Harry Hines Blvd. CS3.104
Dallas, Texas 75235 9109
USA
Tel." +1 214 648 8963
Fax: +1 214 648 7620
e-mail: eellis@mednet.swmed.edu