J Oral Maxillofac Surg66:73-76, 2008

anurS,* A

PhD

f fractodali

ly 200d Max

aucase mallowehe mofrac

tientsurgicaomplius dru

es ar

faciaJ Oral Maxillofac Surg 66:73-76, 2008

Vecainclipchlacanancomaula

*

Join

sio

De

Sci

dad

cab

2

027

doihicle accidents1 and assaults2-9 are the primaryuses of mandible fractures. Signs and symptomslude pain and edema, change in occlusion, lowerparesthesia, abnormal mandibular movements,

ange in facial contour and mandibular arch form,erations, hematoma and ecchymosis, loose teeth,d crepitation on palpation.10 Panoramic radiographsd the lateral oblique view of the mandible as well asmputed tomography (CT) scans are the most infor-tive radiologic exams used in diagnosing mandib-r fractures.

Fracture treatment can be classified by the methodof reduction, as either open or closed. If open reduc-tion is used, it can be further subclassified into non-rigid and rigid fixation (RIF). Thus, all treatment canbe classified as either mandibular closed reductionwith maxillomandibular fixation (MMF), open reduc-tion with MMF, or open reduction without MMF.11

Mandibular fracture treatment by open reduction andRIF provides a number of advantages.12-14 The mostobvious is avoiding MMF, which results in an earlyreturn to function, easier maintenance of oral hy-giene, improved nutrition, and reduced risk of airwaycompromise.15

A displaced fracture in the angle can rarely bereduced satisfactorily by MMF alone. Therefore, anopen reduction and osteosynthesis are more oftenindicated for angle fractures than for other fracturesof the mandibular body. However, several studieshave documented high complication rates after RIF ofthe mandibular angle.14,16-18 The purpose of thisstudy is to review cases of fractures of the mandibularangle and their associated complications.

Patients and Methods

Information was obtained retrospectively from clin-ical notes, surgical records, and radiographs. From

Assistant Professor, Division of Oral and Maxillofacial Surgery,

ville University-Univille, Santa Catarina, Brazil.

Specialist in Dental and Maxillofacial Radiology, Health Divi-

n, Joinville City Hall, Santa Catarina, Brazil.

Professor, Division of Oral and Maxillofacial Surgery, Piracicaba

ntal School, and Division of Plastic Surgery, School of Medical

ences, State University of Campinas-Unicamp, So Paulo, Brazil.

Address correspondence and reprint requests to Dr Passeri: Facul-

e de Odontologia de Piracicaba-Unicamp, Av Limeira, 901 Piraci-

a, So Paulo, Brazil 13414-903; e-mail: passeri@fop.unicamp.br

008 American Association of Oral and Maxillofacial Surgeons

8-2391/08/6601-0012$34.00/0

:10.1016/j.joms.2007.05.025

73Analysis of 115 MFract

Aleysson O. Paza, PhD, MS, DD

Luis A. Passeri,

Purpose: This retrospective study reviewed cases odata, social traits, fracture characteristics, treatment m

Patients and Methods: From April 1999 until Juof the mandibular angle by the Division of Oral anUnicamp, in Brazil.

Results: More angle fractures were observed in Caddiction (62%). Patient mean age was 27 years. Thin altercations, including gunshot wounds (43%), fobeing struck by a car (39%). Open fractures were tside (57%). Only 1 patient sustained bilateral angleopen reduction. Complications occurred in 19 panumber of complications, 3 underwent another scontributed to the development of postoperative cabuse, smoking, and intravenous and nonintraveno

Conclusions: Angle fracture management outcomfixation. 2008 American Association of Oral and Maxillodibular Angleesllan Abuabara, DDS, and

, MS, DDS

ures of the mandibular angle to identify personalties, and postoperative complications.

4, 114 patients were treated for 115 fracturesillofacial Surgery at Piracicaba Dental School-

ian (55%) men (89%) with some kind of drugjority of fractures in this study were sustainedd by vehicle accidents, including bicycles andst frequent (90%), with prevalence of the lefttures. Ninety-seven patients (85%) underwent(17%); 10 (9%) were infections. Of the totall intervention for refixation. The factors thatcations were social risks that included alcoholg abuse.

e affected by many factors beyond method of

l Surgeons

ApforvisDeSogedrugraofanfraintoly

Re

CaagtypnoThtaiveareaffsteciapa

allsuho

UnPoclomitorgicchcame

10therig(1%coturfraipserafraciacoeth

turfra

weincaoftraCowhcoThfix

Di

hig

T

Op1

234

Clo

PazMa

T

PazMa

74 MANDIBULAR ANGLE FRACTUREril 1999 until July 2004, 114 patients were treated115 fractures of the mandibular angle by the Di-ion of Oral and Maxillofacial Surgery at Piracicabantal School, State University of Campinas-Unicamp,Paulo, Brazil. The data recorded included patient

nder, age, etiology, method of surgical treatment,g use, and short-term complications. The radio-phs were evaluated with respect to the conditionthe reduction, dislocation, relapse of the fixation,d fracture union. Success was considered if thecture fixation provided stability, ie, there was noerfragmentary mobility, no infection, and no oste-sis/nonunion of the bone fragments.

sults

A higher prevalence of trauma was observed inucasian (55%) men (89%). The patients meane was 27 years (range, 16 to 62 years), with somee of drug addiction (alcohol, intravenous, andnintravenous drugs) (62%), and dentate (52%).e majority of fractures in this study were sus-ned in altercations (39%), followed by motorhicle accidents (27%). Patient demographic datashown in Table 1. No relevant medical history

ecting bone healing, notably diabetes, prolongedroid therapy, compromised immunity, and asso-ted bony pathology were noted in any of thetients.Of the total (114), 97 patients underwent surgery,under general anesthesia. Two died before the

rgical procedure, 5 patients underwent surgery at aspital that had no affiliation agreement with the

able 1. DEMOGRAPHIC DATA

Number 114Mean age (years) 27Gender (%)

Men 101 (89)Women 13 (11)

Men:women 7.76:1Etiology (%)

Altercation/assault 45 (39)Motor vehicle accident 31 (27)Fall 12 (11)Bicycle accident 10 (9)Sports 6 (5)Gunshot wound 5 (4)Struck by car 3 (3)Work accident 2 (2)

Drug action (%) 71 (62)Alcohol 58 (51)Tobacco 42 (37)Nonintravenous drug 18 (16)Intravenous drug 1 (1)

a, Abuabara, and Passeri. Mandibular Angle Fracture. J Oralxillofac Surg 2008.iversity, and 10 patients did not undergo surgery.stsurgical MMF was used in 3 patients treated withsed reduction, and in 2 patients that had singleniplate fixation. Antimicrobial and anti-inflamma-y drugs were administered for 7 days after all sur-al procedures. An antiseptic mouthwash, 0.12%lorhexidine, was routinely issued for 7 days. Theses were divided into 4 groups on the basis of thethods of fixation (Table 2).Overall, open fractures were the most frequent,3 (90%); 12 (10%) were closed; with prevalence onleft side, 65 fractures (57%); 49 fractures on the

ht side (43%); and only 1 bilateral angle fracture). Isolated fractures of the mandibular angle ac-

unted for 47 patients, and when associated frac-es were detected, the mandibular parasymphysealcture was the most prevalent (26 contralateral, 3ilateral) followed by body fractures (20 contralat-l, 4 ipsilateral), condylar process (6), and ramusctures (1). Other facial fractures occurred in asso-tion with mandibular angle fracture: zygomaticmplex (10), nasal (3), Le Fort I (2), and naso-orbito-moid (1).The mandibular third molar was present in 63 frac-es (55%). A tooth had been extracted from thecture line in 8 patients (Table 3).The most prevalent clinical signs and symptomsre asymmetry, swelling, trismus, pain, and changeocclusion. The time from the initial injury to surgi-l treatment ranged from 2 and 79 days, with mean11.2 days. Fifty-nine patients (63%) were treatednsorally and 35 were treated extraorally (31%).mplications occurred in 19 patients (17%), inich 10 (9%) were infections. Of the total number ofmplications, 3 had further surgery for refixation.e other cases were treated by antibiotics, drainage,ation removal, or MMF (Table 4).

scussion

Fractures of the mandibular angle account for thehest percentage of mandibular fractures in many

able 2. TREATMENT MODALITIES

Treatment N

en reduction 94. Monocortical 1-plate, 2.0 mm superior border(Champy technique19) 40

. Mono and bicortical 2-plate, 2.0 mm 36

. Bicortical 1-plate, 2.4 mm (inferior border plate) 12

. Bicortical 1-plate, 2.4 mm (inferior border plate)and monocortical 1-plate, 2.0 mm (superiorborder) 6

sed reduction 3

a, Abuabara, and Passeri. Mandibular Angle Fracture. J Oralxillofac Surg 2008.

stumoincwiiesincthiextracrorega mamatio

shoffragusidThtwpralsgro

inglintretieplasoingwamainfsev

rat 25 28

atitalunfixstucoassintco19chmationuhigratthetresuvehigobex

ofmianspfrapaingofPretivniqprmepahacecoa c

T

InfInfInfAlvMaTo

PazMa

TO

PazMa

PAZA, ABUABARA, AND PASSERI 75dies. The angle of the mandible is associated com-nly with fractures, for several proposed reasons,luding the presence of the third molar. Consistentth Ugboko et al20 and differing from other stud-,8,21-24 the results of this study did not confirm anreased risk of angle fractures when the mandibularrd molar was present (55%); patients reported thetraction of only 8 (13%) third molars prior touma. However, other reasons, such as the thinnerss-sectional area than that of the tooth-bearingion (biomechanically, the angle can be consideredlever25) and biomechanical forces acting on thendible (including the position of insertion of thesticatory muscles) may influence fracture loca-n.26,27

The group of patients analyzed in this studyowed some interesting features. The most obviousthese was the high proportion of mandibular anglectures that were caused by altercations, includingnshot wounds (43%). The number of patients con-ered drug abusers (62%) was also remarkably high.is showed further evidence of the relationship be-een drugs and interpersonal violence. The largeoportion of alcohol abusers (51%) in this study mayo be a reflection of the social behavior of thisup.Treatment modalities were established consider-the fracture characteristics. Fractures with 1

e and low displacement of the segments wereated by the intraoral Champy technique.19 Pa-nts that presented comminuted fractures, large dis-cement, and considerable injury to the adjacentft tissues and parts were treated extraorally, observ-AO/ASIF principles. It was apparent that infections the commonest type of complication arising fromndibular fracture treatment. The average rate ofection ranges between 5% and 10%,10 althougheral studies have shown higher complication

able 3. STATISTICS ASSOCIATED WITH FRACTURESF THE ANGLE OF THE MANDIBLE

Fracture type (%)Open 103 (90)Closed 12 (10)Comminuted and complex 9 (8)

Side (%)Right 65 (57)Left 49 (42)Bilateral 1 (1)

Third molar status (%)Present 63 (55)Maintained 55 (87)Extracted 8 (13)Absent 52 (45)

a, Abuabara, and Passeri. Mandibular Angle Fracture. J Oralxillofac Surg 2008.es of up to 32% with angle fractures. Preoper-ve oral sepsis, with grossly carious and periodon-ly involved teeth, contributes to the problem, andless decayed teeth are important for reduction andation of the fracture, they should be removed. Thisdy presented a high complication rate (17%). Ac-rding to Passeri et al,11 complications are positivelyociated with chronic abuse of alcohol and non-ravenous and intravenous drugs (the incidence ofmplications was 30% in intravenous drug abusers;% in nonintravenous drug abusers, and 15.5% inronic alcohol abusers). Individuals who did notke chronic use of any drug had a 6.2% complica-n rate. Data analysis showed that of the total, thember of patients considered drug abusers was thehest. This may explain the high complicatione found in this study. Inadequate immobilization offracture segments, prolonged delay in obtaining

atment contributing to infection, inexperiencedrgeons, no cooperation from patients, and the se-rity of the trauma may also have contributed to thish complication rate. Moreover, no difference wasserved between the infection rates of intraoral andtraoral open reduction procedures.Another controversy involved the supplementationfixation with MMF.29,30 Many surgeons still feel thatniplate fixation does not provide adequate stabilityd required MMF for additional security. In a retro-ective study of 287 patients with 499 mandiblectures, Valentino and Marentette31 compared 130tients who underwent intraoral monocortical plat-of matched fractures and found that the addition

MMF did not significantly alter complication rates.in et al32 noted similar findings in a small prospec-e study of 32 patients, combining the old AO tech-ue with MMF. Because the fixation of a fractureovides absolute rigidity and there is no interfrag-ntary mobility, MMF is dispensable. In this study, 3tients were submitted to MMF. In 2 patients, whod a multiple fracture line, the MMF was used suc-ssfully, as an additional precaution and to preventmplications. In the second patient, who presentedomplicated/complex fracture (with considerable

able 4. OVERALL COMPLICATION RATES

Complication N %

ection responding to treatment 10 9ection resulting in plate removal 5 4erior alveolar nerve paresthesia 1 1eolar nerve palsy 1 1locclusion 2 2tal 19 17

a, Abuabara, and Passeri. Mandibular Angle Fracture. J Oralxillofac Surg 2008.

injury to the adjacent soft tissues and parts), a mono-cortical 1-plate 2.0 mm system and postsurgical MMFweeqa snefix

ofcofrasinismevaturredredcoanint2.0opmaopcoanminamiantheduass0%

cluintto

Re1.

2.

3.

4.

5.

6.

7.

8. Safdar N, Meechan JG: Relationship between fractures of themandibular angle and the presence and state of eruption of the

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

76 MANDIBULAR ANGLE FRACTUREre used, because of the unavailability of requireduipment (bicortical 1-plate 2.4 mm). Nevertheless,econd surgical procedure (dental extraction andw fixation system) was necessary and the newation method used was a bicortical 1-plate 2.4 mm.The fixation methods and teeth located in the linefracture were not factors in the development ofmplications. In agreement with Gear et al,33 forctures of the angle of the mandible, the use of agle miniplate on the superior border of mandiblesimple, reliable, and has become the preferredthod of treatment. Ellis25 made a 10-year review ofrious forms of treatment for mandibular angle frac-e, as follows: 1) closed reduction or intraoral openuction and nonrigid fixation; 2) extraoral openuction and internal fixation with an AO/ASIF re-nstruction bone plate; 3) intraoral open reductiond internal fixation using a solitary lag screw; 4)raoral open reduction and internal fixation using 2-mm mini-dynamic compression plates; 5) intraoralen reduction and internal fixation using 2 2.4-mmndibular dynamic compression plates; 6) intraoralen reduction and internal fixation using two non-mpression miniplates; 7) intraoral open reductiond internal fixation using a single noncompressionniplate; and 8) intraoral open reduction and inter-l fixation using a single malleable noncompressionniplate). The results showed that the use of eitherextraoral open reduction and internal fixation withAO/ASIF reconstruction plate, or intraoral open re-

ction and internal fixation, using a single miniplate, isociated with the fewest complications, ranging fromto 7.5%.25

Severity of the trauma and social risk, which in-ded alcohol abuse, smoking, intravenous and non-ravenous drug abuse, were factors that contributedthe development of postoperative infection.

ferencesOlson RA, Fonseca RJ, Zeitter PL: Fractures of the mandible: Areview of 580 cases. J Oral Maxillofac 40:23, 1982Ellis E 3rd, Moos KF, El-Attar A: Ten years of mandibularfractures: An analysis of 2,137 cases. Oral Surg 59:120, 1985Thorn JJ, Mogeltoft M, Hansen PK: Incidence and etiologicalpattern of jaw fractures in Greenland. J Oral Maxillofac Surg52:734, 1986Alan BP, Daly CG: Fractures of the mandible: A 35-year retro-spective study. Int J Oral Maxillofac Surg 19:268, 1990Haug RH, Prather J, Indresano AT: An epidemiologic survey offacial fractures and concomitant injuries. J Oral Maxillofac Surg48:926, 1990Togersen S, Tomes K: Maxillofacial fractures in a Norwegiandistrict. Int J Oral Maxillofac Surg 21:335, 1992Iizuca T, Lindqvist C: Rigid internal fixation of mandibularfractures: An analysis of 270 fractures treated using AO/ASIFmethod. Int J Oral Maxillofac Surg 21:65, 1992lower third molar. Oral Surg 79:680, 1995Greene D, Raven R, Carvalho G, et al: Epidemiology of facial injuryin blunt assault. Determinants of incidence and outcome in 802patients. Arch Otolaryngol Head Neck Surg 123:923, 1997Fonseca RJ, Walker RV, Betts NJ, et al: Oral and MaxillofacialTrauma, vol II (ed 2). Philadelphia, WB Saunders, 1997Passeri LA, Ellis E 3rd, Sinn DP: Relationship of substance abuseto complications with mandibular fractures. J Oral MaxillofacSurg 51:22, 1993Jones JK, Van Sickels J: Rigid fixation: A review of concepts andtreatment of fractures. Oral Surg 65:13, 1988Dodson TB, Perrot DH, Kaban LB, et al: Fixation of mandibularfractures: A comparative analysis of rigid internal fixation andstandard fixation techniques. J Oral Maxillofac Surg 48:362, 1990Tu H, Tenhulzen D: Compression osteosynthesis of mandibular frac-tures: A retrospective study. J Oral Maxillofac Surg 48:585, 1985Gerard N, DInnocenzo R: Modified technique for adapting amandibular angle superior border plate. J Oral Maxillofac Surg53:220, 1995Becker R: Stable compression plate fixation of mandibularfractures. Br J Oral Surg 12:13, 1974Lindqvist C, Kontio R, Pihakari A, et al: Rigid internal fixation ofmandibular fractures: An analysis of 45 patients treated accordingto the ASIF method. Int J Oral Maxillofac Surg 15:657, 1986Peled M, Laufer D, Helman J, et al: Treatment of mandibularfractures by means of compression osteosynthesis. J Oral Max-illofac Surg 47:566, 1989Champy M, Lodde JP, Schmitt R, et al: Mandibular osteosyn-thesis by miniature screwed plates via buccal approach. JMaxillofac Surg 6:14, 1978Ugboko VI, Oginni FO, Owotade FJ: An investigation into therelationship between mandibular third molars and angle frac-tures in Nigerians. Br J Oral Surg 38:427, 2000Tevepaugh DB, Dodson TB: Are mandibular third molars a riskfactor for angle fractures? A retrospective cohort study. J OralMaxillofac Surg 53:646, 1995Wolujewicz MA: Fractures of the mandible involving the im-pacted third molar tooth: an analysis of 47 cases. Br J Oral Surg18:125, 1980Iida S, Hassfeld S, Reuther T, et al: Relationship between therisk of mandibular angle fractures and the status of incom-pletely erupted mandibular third molars. J CraniomaxillofacSurg 33:158, 2005Soriano E, Kankou V, Morand B, et al: Fractures of the mandib-ular angle: Factors predictive of infectious complications. RevStomatol Chir Maxillofac 106:146, 2005Ellis E 3rd: Treatment methods for fractures of the mandibularangle. Int J Oral Maxillofac Surg 28:243, 1999Schubert W, Kobienia BJ, Pollock RA: Cross-sectional area ofthe mandible. J Oral Maxillofac Surg 55:689, 1997Ellis E 3rd: Outcomes of patients with teeth in the line ofmandibular angle fractures treated with stable internal fixation.J Oral Maxillofac Surg 60:863, 2002Ellis E, Sinn DP. Treatment of mandibular angle fractures usingtwo 2.4-mm dynamic compression plates. J Oral MaxillofacSurg 51:969, 1993Raveh J, Vuillemin T, Ladrach K, et al: Plate osteosynthesis of367 mandibular fractures. The unrestricted indication for theintraoral approach. J Craniomaxillofac Surg 15:244, 1987Becker R: Stable compression plate fixation of mandibularfractures. Br J Oral Surg 12:13, 1974Valentino J, Marentette LJ: Supplemental maxillomandibularfixation with miniplate osteosynthesis. Otolaryngol Head NeckSurg 112:215, 1995Prein J, Schilli W, Hammer B, et al: Rigid fixation of facialfractures, in Fonseca RJ, Walker RV: Oral and MaxillofacialTrauma. Philadelphia, WB Saunders, 1991, pp 1206-1240Gear AJL, Apasova E, Schmitz JP, et al: Treatment modalities formandibular angle fractures. J Oral Maxillofac Surg 63:655, 2005

Analysis of 115 Mandibular Angle FracturesPatients and MethodsResultsDiscussionReferences