Oneida Arosarena, Yadro Ducic, and Travis T. Tollefson address questions for discussion and debate:
- 1.
Is rigid fixation essential for the treatment of angle fractures, or is a single plate along the superior border sufficient?
- 2.
Does the presence of teeth in the fracture line (particularly the third molar in angle fractures) contribute to stability of the fixation, or is it a nidus for infection?
- 3.
What is the role of postoperative antibiotics? Are they always necessary?
- 4.
Do you believe that applying MMF is an important part of mandibular fracture repair? If you do not use MMF in all cases, how do you decide which cases require intraoperative and/or postoperative MMF? Do you believe that the techniques/methods of applying MMF make a difference?
- 5.
How do you manage edentulous mandible fractures?
- 6.
Analysis: Over the past 5 years, how has your technique or approach changed or what is the most important thing you have learned in dealing with mandible fractures?
Oneida Arosarena, Yadro Ducic, and Travis T. Tollefson address questions for discussion and debate:
- 1.
- 2.
- 3.
What is the role of postoperative antibiotics? Are they always necessary?
- 4.
- 5.
How do you manage edentulous mandible fractures ?
- 6.
Is rigid fixation essential for the treatment of angle fractures, or is a single plate along the superior border sufficient?
Arosarena
Because of the biomechanics of the mandible, mandibular angle fractures have a high incidence of postsurgical complications. There are currently 2 philosophies espoused by practitioners who use open reduction and internal fixation (ORIF) in the treatment of mandibular angle fractures.
Philosophy 1. The goal of the first group is rigid fixation with 2 miniplates resulting in primary bone union, which necessitates absolute immobility of the fracture fragments according to older Arbeitsgemeinschaft für Osteosynthesefragen–Association for the Study of Internal Fixation guidelines.
Philosophy 2. The second group advocates the use of a single miniplate along the ideal line of osteosynthesis as described by Champy. Although this method does not result in rigid fixation, its proponents list benefits of decreased soft-tissue stripping that maintains blood supply to the mandible, the lack of an external incision, and cost savings related to decreased operative time and savings in hardware. Because bite forces do not return to premorbid levels for several weeks after fracture treatment, proponents of the Champy technique argue that absolute rigid fixation may not be necessary for angle fractures.
Several biomechanical studies have demonstrated that the Champy technique has less favorable biomechanical behavior than biplanar plating techniques. Two studies revealed that a 3-dimensional plate at the superior border of the mandible resulted in increased stability with torsional loading when compared with other commonly used mandibular angle fixation techniques, effecting biplanar fixation with a single plate. However, these studies may represent oversimplified depictions of fractured mandible biomechanics, not taking into account the stabilizing effects of surrounding tissues, particularly muscles. Moreover, these models do not take into account the possibility of stress shielding in the healing mandible that could be attributed to rigid fixation.
In a prospective, randomized trial of 54 patients with unilateral, isolated mandibular angle fractures, Danda found that the use of 2 noncompression miniplates had no advantage over the use of 1 superior border plate, and that the use of 2 miniplates resulted in scarring at the transcutaneous incision in 18% of patients. However, Danda used 2 weeks of interdental fixation in all patients. Similarly, in a study of 185 patients with isolated unilateral angle fractures, Ellis found no significant difference in treatment outcomes for patients treated with rigid versus nonrigid fixation, although patients treated with rigid fixation in this study had longer operative times and more wound problems. A recent meta-analysis of mandibular angle fixation techniques found lower complication rates with the use of 1 superior border plate compared with the use of 2 plates.
Ducic
The decision as to which method of fixation is most appropriate will, of course, be determined by the specific type of injury present. There are several options in treating these injuries with respect to fixation modality. Closed reduction is still an option. However, there is a prolonged period of immobilization that may be associated with increased rate of long-term temporomandibular joint problems. Closed reduction is relatively contraindicated in comminuted angle fractures because of the increased risk of complications. Rigid load-bearing plating of angle fractures is needed in comminuted fractures. Compression plating and lag screw fixation is not appropriate in these circumstances, because of the potential for fragmentary telescoping. Studies performed in noncomminuted angle fractures demonstrate a decreased risk of complications with a single superior border monocortical miniplate placed along Champy’s ideal line of osteosynthesis, slightly greater complication rate with an inferior border bicortical plate, and the greatest rate of complications with 2 separate plates.
Tollefson
In treatment of fractures of craniomaxillofacial skeleton, is it not rigid truth that 2 plates are better than 1? Unfortunately, the relationship of bioengineering concepts to the clinical application of rigid fixation is not as linear as we would expect. Practice patterns in mandible fracture management have steadily evolved over the last century, with surges of major advances from both bioengineering and clinical fields. Ellis recently reported superiority of the single miniplate technique for mandibular angle fractures over either maxillomandibular fixation after closed reduction or 2-plate fixation. He cited fewer complications and shorter operative time. I concur with the application of a single plate at the mandibular oblique line for treatment of angle fractures in the following circumstances:
- 1.
Adequate bone stock is available
- 2.
Comminution or bone defect (eg, gunshot wound) is not present
- 3.
Nonedentulous
- 4.
In the presence of adequate dentition to restore occlusion.
I will briefly introduce the state of the science by reviewing the theories of rigid versus adaptive fixation and the reports of the outcomes of their application.
Without considering the extremes of treatment trends, the contemporary history of mandible fracture treatment paradigms can be simplified into 2 different schools:
- 1.
Treatment patterns restricting function and movement (with external fixation, wires, and load-bearing internal fixation)
- 2.
Shift to near immediate return to function with limited, site-directed internal plate fixation.
The latter incorporates the concept of adaptive osteosynthesis, which has come to be colloquially referred to as the Champy technique in reference to his expansion on the work of Michelet ( Fig. 1 ). The former, adapted from Association for Osteosynthesis/Association for the Study of Internal Fixation (AO-ASIF) orthopedic management principles of long bone fractures, is supported because of the establishment of rigid fixation for primary bone healing by limiting motion around the fracture ( Figs. 1–4 ).
