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J Oral Maxillofac Surg68:2743-2754, 2010

A Prospective Study of 3 TreatmentMethods for Isolated Fractures of the

Mandibular AngleEdward Ellis III, DDS, MS*

Purpose: The purpose of this investigation was to evaluate treatment outcomes prospectively whenisolated fractures of the mandibular angle are treated by 1) nonrigid fixation that includes 5 to 6 weeksof maxillomandibular fixation, 2) nonrigid but functionally stable fixation using a single miniplate, and3) rigid fixation using 2 miniplates.

Patients and Methods: All patients treated for isolated fractures of the mandibular angle at ParklandHospital over a 12-year period were treated by 1 of the 3 methods sequentially assigned. Demographic,fracture characteristic, and treatment and outcome data were prospectively collected and statisticallyanalyzed to determine whether the 3 treatments produced different outcomes.

Results: One hundred eighty-five patients had sufficient follow-up for inclusion in this study. Therewere no significant differences in demographic data for the 3 groups. There were significant differencesin treatment outcomes for several variables, including the amount of time it took to perform the surgeryand postoperative wound problems.

Conclusion: The use of single miniplate was the easiest to perform and was associated with the lowestnumber of complications.© 2010 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 68:2743-2754, 2010
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he treatment of mandibular angle fractures is plaguedith the highest postsurgical complication rate of allandibular fractures.1-5 Even traditional treatmentethods have a high complication rate (17%) in someatient populations.5 Plate and screw fixation devicesave revolutionized the treatment of angle fractures;owever, complication rates vary widely from oneenter to another6-9 and from one fixation scheme tonother.10-14

There are 2 general philosophies espoused by users oflate and screw fixation for mandibular fractures. Oneroup believes that plate and screw fixation shouldrovide sufficient rigidity to the fragments to prevent

nterfragmentary mobility during active use of the man-ible (rigid fixation). This group recommends placing

arge bone plates fastened with bicortical bone screws,large and 1 small bone plate, or 2 small plates to

*Professor, Oral and Maxillofacial Surgery, The University of

exas Health Science Center at San Antonio, San Antonio, TX.

Supported by a grant from AO North America.

Address correspondence to Dr Ellis: University of Texas Health

cience Center, 7703 Floyd Curl Dr, MC 7908, San Antonio, TX

8229-3400; e-mail: [email protected]

2010 American Association of Oral and Maxillofacial Surgeons

278-2391/10/6811-0015$36.00/0

toi:10.1016/j.joms.2010.05.080

2743

rovide such rigidity.6-8,15-19 Primary bone union, whichecessitates absolute immobility of fragments, is theoal of treatment of mandibular fractures by these sur-eons.In 1973, Michelet et al20 reported the treatment ofandibular fractures using small, easily bendable non-

ompression bone plates, placed transorally, attachedith monocortical screws. Champy et al9 performed

everal investigations with a “miniplate” system toalidate the technique. In their experiments, theyetermined the “ideal line of osteosynthesis” for frac-ures of the mandibular angle is the positioning of thelate along the superior border of the mandible. Un-

ike in some surgeries, absolute immobilization ofone fragments and primary bone union was deemednnecessary. This technique of fixation could be cat-gorized as nonrigid, but because the patient did notave to have immobilization of the jaws, it could alsoe categorized as “functionally stable fixation.” Clini-al studies have proven the usefulness of this tech-ique.14,20-30

The controversy still rages between advocates ofrigid” fixation, which usually requires application of 2one plates, and those who use nonrigid but function-lly stable fixation by application of a single miniplate.owever, there are those who believe that the time-onored nonrigid method for treatment of angle frac-
ures is preferred, using either closed or open reduction
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Edward Ellis III. Isolated Fractures of the Mndibular Angle. J OralMaxillofac Surg 2010.

2744 ISOLATED FRACTURES OF THE MNDIBULAR ANGLE

nd internal fixation with a transosseous wire plus sev-ral weeks of maxillomandibular fixation (MMF).30

ertainly, if a single miniplate can provide similar oretter results than the application of 2 bone plates, thereill be cost savings both from the savings in hardware

nd from the time in surgery necessary to apply theecond bone plate. If the patient can return to normalaily activities sooner when using plate or screw fixa-ion (or a combined method), the cost to society of suchnjuries will be minimized.

It is unclear on the basis of clinical studies whetherbsolute rigid fixation should be used. Studies that favorne method of fixation over another are available. Theroblem with most of the clinical studies in the litera-ure is that they are retrospective, nonrandomized, anday include patients who also have fractures of other

egions of the mandible in addition to the angle. Theurpose of this prospective study was to determinehether there is any difference in outcomes when iso-

ated fractures through the angle of the mandible arereated with nonrigid fixation and 5 to 6 weeks of MMF,unctionally stable but nonrigid fixation with a singleiniplate, or rigid fixation using 2 miniplates.

atients and Methods

All dentate patients 13 years or older with isolatedie, no other mandibular or maxillary), noncommi-uted fractures through the mandibular angle whoresented for treatment at Parkland Hospital betweenpril 1997 and July 2009 were included in this insti-

utional review board–approved study. To be in-luded, they must have had sufficient dentition toetermine proper occlusion. Exclusion criteria in-luded 1) the fracture was infected at the time ofreatment, 2) medical conditions that could possiblyave interfered with healing (HIV positivity, diabetes,hemotherapy, etc) or prevented general anesthesia,nd 3) less than 6 weeks of follow-up.

Patients were sequentially assigned to 1 of 3 treat-ent groups: 1) nonrigid fixation using open reduc-

ion and internal wire fixation plus 5 to 6 weeks ofMF, 2) open reduction and internal fixation using a

ingle miniplate attached along the superior border ofhe mandible using at least 2 2.0-mm-diameter screwsn each side of the fracture, 3) open reduction and

nternal fixation using 2 miniplates, 1 at the superiororder and 1 along the inferior border of the mandi-le, attached with at least 2 2.0-mm-diameter screwsn each side of the fracture.Data were prospectively collected (Table 1) on the

atients and their treatment using a data collectionorm. The data were then input into a Microsoft Excelpreadsheet (Microsoft, Redmond, WA). Descriptivend inferential statistics were performed using XLSta-
istics (version 08.05.12, 1997-2008, Rodney Carr, free-
Table 1. DATA COLLECTED ON PATIENTS

Demographic Variables

geenderaceedical issues, including: presence of diabetes, steroid use,human immunodeficiency virus, chemotherapy, radiationtherapy, nutritional deficiencies, alcohol use (quantity,frequency), intravenous and nonintravenous drug use(quantity, frequency)

merican Society of Anesthiology classificationause of injury (altercation, motor vehicle, sport, fall,occupational, other)

Fracture Characteristics

ide of fracture (right vs left)ontamination of fracture (open vs closed)isplacement (non, minimal, moderate, severe)resence of tooth in line of fractureocation of tooth in fracture (proximal vs distal segment)ruption status of tooth in line of fracture (impacted, partiallyerupted, erupted)obility of tooth in line of fracture (mobile, nonmobile)resence of pericoronitis of tooth in line of fractureracture of tooth in line of fracture (yes, no)ecay in tooth in line of fracture (yes, no)eriodontitis of tooth in line of fracture (yes, no)mount of root exposure to fracture (minimal, up to 0.5 of root,most/all of root)

eurosensory deficit of mental nerve (none, hypesthetic,anesthetic, dysesthetic)

Treatment Variables

reatment groupuration between injury and presentationuration between injury and surgical treatmenturation between injury and receiving antibioticsuration between surgery and dischargeemoval of tooth in line of fracture (yes, no)urgical time from incision to last suture (and to the application

of maxillomandibular fixation in the nonrigid group)urgeon’s assessment of ease of application of fixation device(s)

(simple, some difficulty, very difficult)ostoperative radiographic evaluation of reduction (good,moderate, poor)

Outcome Variables

hort-term evaluation of occlusion (normal, malocclusion)se of elastics to treat any malocclusion (yes, no)ound problems (cellulitis, purulence, dehiscence of incision,plate exposure, granulation tissue at incision) (yes, no)

ime between surgery and wound problemeed for treatment of any complication (yes, no)ethods of treatment for any complication including type ofanesthesia (local, general), location where complication wastreated (ie, clinic, operating room, etc), need for hardwareremoval, etc)

ollow-up durationcclusion at last follow-up visit (normal, malocclusion)ssessment of fracture fragment alignment in latest radiograph(good, moderate, poor)

nterincisal dimension at latest follow-uplinical union at latest follow-up (yes, no)alpability of hardware at latest follow-up (yes, no)eurosensory dysfunction of mental nerve at latest follow-up(none, hypoesthetic, anesthetic, dysesthetic)

otal no. of postoperative visits

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EDWARD ELLIS III 2745

are available at [email protected]). Compara-ive statistics of nonparametric categorical variablesas performed using �2 cross-table analysis. Compar-

tive statistics of parametric data were performedsing 1-way analysis of variance. If a difference ex-

sted, post hoc t tests were performed to compare thendividual groups. Differences were considered statis-ically significant if the confidence interval was P lesshan .05.

SURGICAL TECHNIQUES

Patients received systemic antibiotics from the timef presentation. The fractures were not considerededical emergencies and were scheduled electivelyhen operating room time permitted, but usuallyithin 1 or 2 days after presentation.

Nonrigid FixationAfter placement of arch bars, the fracture was ex-

osed using an intraoral incision. Only the amount ofoft tissue stripping necessary to visualize, reduce,nd stabilize the fracture was performed. Mobile teethr teeth with apices that were exposed in the fractureere removed. If teeth in the fracture site were to be

xtracted, the intraoral incision included the attachedingiva around the involved tooth. A Kirschner or-wire was inserted through the skin (without a tro-har) and used to drill a hole through the mandible onach side of the fracture, usually into the sockethere a tooth had been extracted. Otherwise, theole was created through both the buccal and lingualortices. A 24-gauge wire was then passed betweenhe fragments and twisted together with the fractureeduced and the patient’s mandible held in MMF. Theire was cut and the end adapted to the outer cortex.he soft tissue flap was undermined, and closure waserformed with resorbable suture. No drains weresed. Postsurgical MMF was secured using 3 or 44-gauge wires around the arch bars.

Single MiniplateAfter placement of arch bars, the fracture was ex-

osed using an intraoral incision. Only the amount ofoft tissue stripping necessary to visualize, reduce,nd stabilize the fracture was performed. Mobile teethr those with apices exposed in the fracture wereemoved. If teeth in the fracture site were to bextracted, the intraoral incision included the attachedingiva around the involved tooth. The fracture washen reduced and the jaws placed into MMF. A 4-holeoncompression titanium miniplate (Synthes Maxillo-acial, Paoli, PA; or Walter Lorenz Surgical, Jackson-ille, FL) was adapted along the medial side of thexternal oblique ridge and screwed to the bone using.0-mm self-threading screws. No transbuccal trocharas necessary for instrumentation. The 3 most ante-

ior screws were inserted with the patient in MMF. w

he most posterior screw, which was on the medialurface of the mandibular ramus, was in some casesnserted after removing the MMF, allowing instrumen-ation between the upper and lower teeth from thepposite side. After the plate was placed, MMF wiresere removed, and the occlusion was checked. Post-

urgical MMF was not used in any patient. The inci-ion was closed with resorbable suture, and no drainsere placed.

Two MiniplatesIn addition to what was just described for the singleiniplate group, a second miniplate was adapted and

crewed to the inferior portion of the buccal cortexsing 2.0-mm screws. This required much more sub-eriosteal dissection to expose the inferior border ofhe mandible. The screws were self-threading andlaced through a transbuccal trochar. After the platesere placed, MMF wires were removed, and the oc-

lusion was checked. Postsurgical MMF was not usedn any patient. The incision was closed with resorb-ble suture, and no drains were placed.

Postsurgical ManagementAntibiotics were continued through the periopera-

ive period and for 5 to 7 days after surgery. Foratients not allergic to penicillin, an intramuscularepot injection (1 million U) of procaine penicillin Gas administered before the patient was awakened

rom anesthesia so that compliance with antibioticse would not be a factor. For those patients allergico penicillin, an oral regimen of clindamycin wasrescribed. Chlorhexidine mouth rinse was provided

or all patients. Dietary consultation for patientslaced into postsurgical MMF was provided. For pa-ients not placed into MMF, no dietary recommenda-ions were made. For patients in MMF, the wires wereemoved at 5 weeks, but the arch bars were left inlace. Arch bar removal for all patients occurred onceheir interincisal opening was 40 mm or greater. Elas-ics were not used unless the patient had a malocclu-ion that required occlusal guidance. They were usednly as long as necessary to obtain the proper occlusalelationship.

esults

Two hundred twenty-eight patients were enrolledn the study, but 43 were not operated on with theuthor available, were lost during the follow-up pe-iod, or never returned for an evaluation at the 6-weekeriod or later. The final study sample included 185atients with 60 in group 1, 62 in group 2, and 63 inroup 3. The demographics of the population areresented in Table 2. Not surprisingly, males greatlyutnumbered females (161 vs 24), and the mean age
as in the 20- to 30-year-old range. African Americans
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ere the most common racial group (n � 77), fol-owed by whites (n � 58) and Hispanics (n � 50).lso not surprisingly, the vast majority of fracturesere sustained in altercations (n � 134), followed by

ports and motor vehicle accidents (n � 14 each),alls (n � 13), other causes (n � 8), and occupationalccidents (n � 2). Medical conditions of the patientsere few. Only 1 patient had taken steroids and thatas over a year before surgery, 1 patient was diabetic,

here were no cases of human immunodeficiencyirus, chemotherapy, radiation therapy, or obviousutritional deficiencies. Alcohol use was common, asas a history of nonintravenous drug use. However,

ew patients had a history of intravenous-drug usen � 10). The vast majority of patients were classifieds ASA I or II, with only 3 patients classified as III, ando IVs or Vs. There was no statistically significantifference in any of the demographic variables amonghe treatment groups.

The variables describing the characteristics of theracture are presented in Table 3. Given that alterca-ions were the most common cause of fractures, ithould not be surprising that the majority were on theeft side (n � 124/185; 67%). Most were considered

Table 2. DEMOGRAPHIC VARIABLES BY GROUP

T

1 (nonrigid)

60ender Male: 51 Mal

Female: 9 Femge (years) x � 27.4 (range 14-49) x �ace White: 21 Wh

Hispanic: 12 HispAA: 27 AA:

ause Altercation: 42 AlteFall: 7 FallSport: 3 SpoMVC: 3 MVCOccupational: 1 OccOther: 4 Oth

lcohol (drinks/day)x � 1.13 range � 0-12

SD 2.1x �

SD

lcohol (years of use)x � 5.03 range � 0-30

SD 7.5x �

SDV drug use

(currently)No 60 NoYes: 0 Yes

V drug use (ever) No 57 NoYes: 3 Yes

on-IV drug use(currently)

No 8 NoYes: 52 Yes

SA I: 32 I. 3II: 28 II. 2III: 0 III.

bbreviations: AA, African American; ASA, American Society

dward Ellis III. Isolated Fractures of the Mndibular Angle. J Ora

ompound, or open to the oral cavity (n � 163/185; l

8%), and most were minimally or moderately dis-laced (160/185%, 86%). Teeth were present in the

ine of the angle fracture in most cases (167/185%,0.3%) and were relatively equally distributed be-ween being contained within the proximal and distalegments. The teeth were more often mobile than notn � 114/185; 61%) and were fractured in 30 (16%)ases. Just over half were erupted or partially erupted107/185%, 57.8%), but even the ones classified asmpacted were rarely completely encased in bone. Inhose cases of teeth involved in the fracture (n �67), the teeth were not commonly decayed (23/167,4%) or periodontally involved (27/167, 16%) andnly occasionally had pericoronitis (13/167, 8%). Themount of root exposed to the fracture was variable,ut in the majority of instances, from half to the entireoot was completely exposed to the fracture site andevoid of bone (114/167, 68%). Neurosensory deficitsf the mental nerve were quite variable, and the patientas often anesthetized before surgery. Patients rarelyresented immediately after their injury. The averageatient arrived 2 days after injury, and therefore anti-iotics were not begun until that time. The durationetween injury and surgical treatment was much

ent Group

Significanceiniplate) 3 (2 miniplates)

62 63Male: 55 nsFemale: 8

range 13-51) x � 27.8 (range 17-54) nsWhite: 19 ns

17 Hispanic: 21AA: 23

n: 48 Altercation: 44 nsFall: 3Sport: 7MVC: 6

nal: 0 Occupational: 1Other: 2

ange � 0-12 x � 1.98 range � 0-12SD 2.7 ns

ange � 0-25 x � 5.30 range � 0-30SD 7.2 ns

No 60 nsYes: 3No 60 nsYes: 3No 14 nsYes: 49I. 39 nsII. 21III. 3

esthesiology; IV, intravenous; MVC, motor vehicle collision.

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ays. None of the fracture characteristic variablesmong the treatment groups were statistically signif-cantly different from one another.

The variables describing the treatment provided tohe patients are presented in Table 4. During theurgery, 150 of the 167 teeth present in the line of thengle fracture were extracted (89.8%), with no differ-nce among the groups. The time required to provideurgical treatment in the operating room varied from3 to 70 minutes, with an average of 29.5 minutes.here was a statistically significant difference among

he groups for the duration of surgery (P � .001) withroup 2 having the shorter time (x � 23.5 minutes),ollowed by group 1 (x � 27.8 minutes). Group 3 had

Table 3. FRACTURE CHARACTERISTICS BY GROUP

1 (nonrigid) (n � 60)

ide of Fx Left: 45Right: 15

pen versus closed Fx Open: 52Closed: 8

isplacement None: 5Minimal: 30Moderate: 25Severe: 0

ooth in Fx No 9Yes: 51

ooth in which segment? Proximal: 25Distal: 26

osition of tooth Erupted: 14Partial: 13Impacted: 24

ooth mobility Mobile: 33Nonmobile: 18

racture of tooth No: 41Yes: 10

ericoronitis No: 50Yes: 1

ooth decayed? No: 46Yes: 5

eriodontitis of tooth? No: 42Yes: 9

mount of root exposed to Fx Minimal: 17Up to half: 20Most or all: 14

eurosensory deficit beforesurgery

None: 24Hypesthetic: 29Anesthetic: 7

uration between injury andpresentation (days)

x � 2.60 range � 0-21SD � 4.0

uration between injury andantibiotic administration (days)

x � 2.59 range � 0-21SD � 3.8

uration between injury andsurgery (days)

x � 5.52 range �1-22 SD � 4.0

bbreviation: Fx, fracture.


he longest time (x � 37 minutes). The surgeons o

learly rated group 2 as being easier surgeries toerform than those of groups 1 or 3 (P � .001).The analysis of outcomes is presented in Table 5.

he time between surgery and discharge averaged 1ay, with a range of 0 to 11 days. The duration ofollow-up averaged 162 days with no significant dif-erence among the groups. Analysis of the immediateostoperative radiograph showed good reduction ofhe fracture in the vast majority of cases (166/185,9.7%). There was no statistically significant differ-nces among the treatment groups for this variable.ound problems were encountered in 25 patients, 9

n group 1, 2 in group 2, and 14 in group 3 (Table 6).here was a statistically significant difference in the

reatment Group

Significance1 miniplate) (n � 62) 3 (2 miniplates) (n � 63)

: 38 Left: 41 nst: 22 Right: 22n: 56 Open: 55 nsed: 4 Closed: 7e: 3 None: 7 nsimal: 36 Minimal: 30erate: 16 Moderate: 23re: 5 Severe: 3

3 No 4 ns57 Yes: 59imal: 28 Proximal: 25 ns

al: 29 Distal: 34ted: 17 Erupted: 23 ns

ial: 17 Partial: 23acted: 23 Impacted: 13ile: 40 Mobile: 41 nsmobile: 17 Nonmobile: 1846 No: 50 ns11 Yes: 9

53 No: 51 ns4 Yes: 8

49 No: 49 ns8 Yes: 10

49 No: 49 ns8 Yes: 10

imal: 19 Minimal: 19 nsto half: 24 Up to half: 23t or all: 14 Most or all: 17e: 24 None: 29 nsesthetic: 33 Hypesthetic: 31sthetic: 5 Anesthetic: 32.18 range � 0-28� 4.3

x � 1.44 range � 0-12SD � 2.3

ns

2.05 range � 0-28� 4.3

x � 1.77 range � 0-12SD � 2.4

ns

5.36 range �29 SD � 4.9

x � 4.73 range �0-19 SD � 3.5

ns

illofac Surg 2010.

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LeftRighOpeClosNonMinModSeveNoYes:ProxDistErupPartImpMobNonNo:Yes:No:Yes:No:Yes:No:Yes:MinUpMosNonHypAnex �

SDx �

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1-

ccurrence of a postoperative wound problem among

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he groups (P � .01). Eighteen of the 25 patients withound problems required removal of their internalxation device(s) (5 of 9 in group 1, 1 of 2 in group, 11 of 14 in group 3). Seven of 18 times, this coulde performed in the clinic under local anesthesia, buthe remainder had to have a general anesthesia in theperating room to remove the hardware. This wasspecially common in group 3, in whom 7 of 11atients who required hardware removal required aeneral anesthetic to do so. Although incision andrainage procedures were performed from both intra-nd extraoral approaches, hardware removal was al-ays performed through an intraoral approach. Fig-res 1 and 2 show representative cases of complica-ions.

Wound problems occurred at various times afterurgery but averaged 3 weeks of more. There was notatistically significant difference between the timeetween surgery and discovery of a wound problemmong the 3 groups. At the last postoperative visit,here were 7 cases of malocclusion, none of whichere in group 2. However, there was no significantifference among the groups. Interestingly, thereere many more cases (n � 22) of fracture mobilityetected at latest follow-up (P � .01), but most ofhese were extremely minor. Not surprisingly, group

had the largest number of cases in which someovement at the fracture site with bimanual manip-

lation could be detected (n � 14). The maximumnterincisal dimension at last follow-up averaged over0 mm in all 3 groups, although there was a signifi-ant difference among them (P � .05), with group 1aving a slightly lower mean value than the others.here were no significant differences in the neurose-ory deficits or the radiographic interpretation ofracture alignment at the latest follow-up visit, noras there any difference in the number of postoper-

Table 4. TREATMENT VARIABLES BY GROUP

Treatment G

1 (nonrigid) (n � 60) 2 (1 miniplate)

xtraction oftooth in Fx?

No: 2 No: 7Yes: 49 Yes: 50

urgical time(min)

x � 27.8 range � 14-70SD � 9.04

x � 23.5 rangeSD � 7.9

ase of surgery Simple: 32 Simple: 57Some difficulty: 23 Some difficultyDifficult: 5 Difficult: 0

bbreviation: Fx, fracture.


tive visits among the groups. s

iscussion

Over the course of several years, we performed vari-us treatment schemes for fractures of the mandibularngle on a consecutive series of patients.5,10-14,31-35 Inne of those studies, we showed that treatment ofngle fractures even using traditional methods—losed reduction and/or open reduction and internalire fixation—produced a high rate of complication

17%) in our patient population.5 The most usefulechniques in our population were either an extraoralpen reduction and internal fixation with the AO/SIF reconstruction plate,11 or intraoral open reduc-

ion and internal fixation using a single miniplate.14

he use of the reconstruction bone plate was alsoound to result in few complications in a study ofngle fractures by Iizuka and Lindqvist.36 However,he application of this plate for fractures of the anglef the mandible is much easier through an extraoralpproach, an approach that can create its own set ofomplications (eg, facial nerve injury, scars, etc). Forhese reasons, we currently use transoral approachesn the vast majority of fractures through the mandib-lar angle, and most commonly, a single 2.0-mminiplate is used along the superior border as advo-

ated by Champy.9

The results of the consecutive series of clinicalnvestigations performed in our hospital on a similaratient population indicate that, contrary to popularelief, up to a point, the incidence of major compli-ations after fractures of the mandibular angle arenversely proportional to the rigidity of the fixationpplied when an intraoral approach is used. Everyttempt we made at using a 2-plate technique via aransoral approach was fraught with high rates ofequestrectomy, infection, and need for subsequent

Significance) 3 (2 miniplates) (n � 63)

No: 8 nsYes: 51

54 x � 37.0 range � 21-68SD � 9.6

Overall: P � .001Groups 1 and 2: P � .01Groups 1 and 3: P � .001Groups 2 and 3: P � .001

Simple: 27 Overall: P � .001Some difficulty: 27 Groups 1 and 2: P � .001Difficult: 9 Groups 1 and 3: ns

Groups 2 and 3: P � .001

illofac Surg 2010.

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urgery. However, this finding is not universal, and

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here are other similar studies in the literature thathow 2 miniplates perform better than one.15,19,37

The problem with most of the clinical studies ishat they are series of patients treated with a certainechnique (case series),5,10-14,16,25,31,34-37 usually ret-ospective or may include patients who also haveractures in other regions of the mandible in additiono the angle, such as the contralateral body or sym-hysis.5,10-14,16,27,31-41 The only prospective or ran-omized studies performed on fractures through theandibular angle include patients who have concom-

tant fractures elsewhere in the mandible.38-41 Theesults of those investigations showed that single

Table 5. OUTCOME VARIABLES BY GROUP

T

1 (nonrigid) (n � 60) 2 (1

uration between surgeryand discharge (days)

x � 1.13 range � 0-11SD � 1.5

x � 0SD

ollow-up duration (days) x � 159.12 x � 1valuation of immediatepostoperative x-rays

Good: 54 GoodNot good: 6 Not g

ound problems (seeTable 6)

n � 9 n � 2

uration between surgeryand wound problem(days)

x � 49.3 range � 3-151SD � 44.3

x � 6SD

cclusion at last follow-up visit

Good: 56 GoodMalocclusion: 4 Malo

linical union at lastfollow-up visit

No: 14 No: 5Yes: 46 Yes:

inal interincisaldimension (mm)

x � 41.21 range �10-60 SD � 9.9

x � 430-

eurosensory None: 32 Noneysfunction at lastfollow-up visit

Hypesthetic: 11 HypeAnesthetic: 3 AnesDysesthesia: 0 Dyse

-ray at last follow-upvisit

Good: 53 GoodModerate: 3 ModePoor: 4 Poor

o. of postoperative visits x � 2.98 range � 1-8SD � 1.5

x � 2SD


iniplate fixation of mandibular angle fractures pro- e

ides similar or better results (ie, fewer complica-ions) when compared with other treatments.

Because of the inherent problems in the literatureith most studies, this prospective study was in-

ended to determine whether there is any differencen outcomes when isolated fractures through the an-le of the mandible are treated with nonrigid fixationnd 5 to 6 weeks of MMF, functionally stable butonrigid fixation with a single miniplate, or rigidxation using 2 miniplates. An attempt was made toontrol as many variables as possible. For instance, allases had to have been performed with the surgeonthe author) scrubbed in surgery. This eliminated sev-

ent Group

Significanceate) (n � 62) 3 (2 miniplates) (n � 63)

nge � 0-6 x � 0.85 range � 0-2SD � 0.4

ns

x � 195.52 nsGood: 53 ns

3 Not good: 10n � 14 Overall: P � .01

Groups 1 and 2:P � .05

Groups 1 and 3:ns


nge � 37-866

x � 45.14 range � 9-101SD � 23.4

ns

Good: 60 nsn: 0 Malocclusion: 3

No: 3 Overall: P � .01Yes: 60 Groups 1 and 2:

P � .05Groups 1 and 3:

P � .01Groups 2 and 3:

nsange �� 5.8

x � 43.92 range �34-65 SD � 6.2

Overall: P � .05


Groups 1 and 3:ns

Groups 2 and 3:ns

None: 31 ns: 5 Hypesthetic: 171 Anesthetic: 3: 0 Dysesthesia: 1

Good: 59 nsModerate: 3Poor: 1

nge � 1-5 x � 2.62 range � 1-9SD � 1.5

ns

illofac Surg 2010.

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.83 ra� 0.831.79: 59ood:

1.5 ra� 34.

: 62cclusio

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4.59 r65 SD

: 37stheticthetic:sthesia: 60rate: 1

: 1.36 ra� 1.1

ral cases from the original group of patients. Isolated

Table 6. WOUND PROBLEMS BY GROUP

Cellulitis Purulence DehiscencePlate/WireExposure

GranulationTissue

Oral AntibioticCurative?

I&D Required?(IO vs EO)

Plate/Wire RemovalRequired?

Location WhereManaged/Anesthesia Details

Group 1 (Intraosseous Wire � MMF)1 x x x No EO Yes hosp/GA Last follow-up showed poor reduction and

malocclusion but Fx stable2 x x x No IO No Clinic/LA Patient cut himself out of MMF at 5 weeks;

Did not return until weeks later. Lastfollow-up showed poor reduction of Fx,malunion, and malocclusion

3 x x Patient cut himself out of MMF at 4 weeks;ramus rotated into oral cavity. Malunion/malocclusion; no infection; osteotomyplanned, but patient did not return for it

4 x Yes5 x x YES Hosp/GA Union, good occlusion6 x Yes Patient cut himself out of MMF � 2; union,

good occlusion7 x x x Yes Union, good occlusion8 x x x x No EO Yes Hosp/GA Nonunion, malocclusion, reconstructed

plate applied, good outcome9 x x x x No Yes Clinic/LA Union, good occlusion

Group 2 (1 miniplate)1 x Yes Union, good occlusion2 x No Yes Clinic/LA Union, good occlusion

Group 3 (2 miniplates)1 x x x x No Yes (upper plate) Clinic/LA Union, good occlusion2 x Yes Yes (one loose screw) Union, good occlusion3 x Yes Union, good occlusion4 x x No IO Yes Hosp/GA Union, good occlusion5 x x x Yes Union, good occlusion, imperfect reduction6 x x x Yes Clinic/LA (upper plate only) Union, good occlusion, imperfect reduction7 x x x x No Yes Hosp/GA At time of plate removal, Fx not healed,

malocclusion; MMF required,subsequently union/good occlusion.

8 x x No Yes Hosp/GA Union, good occlusion9 x x x x No Yes Hosp/GA Union, good occlusion

10 x x x x x No IO Yes Hosp/GA Union, good occlusion11 x x x x No IO Yes Hosp/GA Union, good occlusion12 x Yes Hosp/GA Union, good occlusion13 x x x No IO Yes Clinic/LA Union, good occlusion14 x x x x No IO Yes Clinic/LA At time of plate removal, Fx not healed;

MMF required, good occlusion;subsequently healed.

Abbreviations: EO, extraoral; Fx, fracture; GA, general anaesthesia; Hosp, hospital; I&D, incision and drainage; IO, intraoral; LA, local anesthesia; MMF, maxillomandibularfixation.

Edward Ellis III. Isolated Fractures of the Mndibular Angle. J Oral Maxillofac Surg 2010.

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IGURE 1. Case of isolated left angle fracture treated with intraosseous wire plus maxillomandibular fixation (MMF). A, Preoperativeanoramic radiograph; B, intraoperative photograph after extraction of third molar and placement of intraosseous wire; C, immediatelyostoperative panoramic radiograph showing intraosseous wire and MMF; D, intraoral photograph taken 9 weeks postoperatively showingony sequestrum (arrow); E, photograph showing abscess that developed; F, panoramic radiograph taken after debridement, wire removal,nd incision and drainage (note: MMF required); G, panoramic radiograph taken 4 weeks after sequestrectomy and debridement. Theatient had good occlusion and minimal mobility across fracture site at this time.

dward Ellis III. Isolated Fractures of the Mndibular Angle. J Oral Maxillofac Surg 2010.

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ractures were part of the inclusion criteria so theariables involved in biomechanics and treatment of aouble fracture could be eliminated as a factor in theutcome. Unfortunately, isolated fractures of the an-le are much less common in clinical practice thanhe combination of an angle and contralateral body orymphysis fractures, so acquisition of a sufficient sam-le took 12 years. However, it is believed that aecond fracture in the mandible can confound theutcome data because the fixation requirements of aouble fracture are often different from those for an

solated fracture.42-44 Furthermore, if a malocclusions noted, it is not always possible to determine whichf the fractures may be contributing to the malocclu-ion.

One might criticize the design of this prospectivetudy in that the assignment of patients to treatmentroups was nonrandomized. Instead, a fixed patternf assignment of treatment was performed. In a fixedattern design of assigning patients in a study with 3reatment groups, the first patient is assigned to treat-

IGURE 2. Case of isolated left angle fracture treated with 2 minipadiograph; C, intraoral photograph taken 4 weeks later showinraining through trochar site; E, panoramic radiograph taken at 4late (arrow); F, bone plates and sequestrum after removal; G, panote: maxillomandibular fixation required); H, panoramic radiogracross fracture site.


ent group 1, the second patient to treatment group i

, the third patient to treatment group 3, and theourth patient begins the cycle again. The reason forhis is that there was an ulterior motive in treatmentroup assignment. Beyond the study being per-ormed, an overriding desire was to have the residentsotating through the Parkland Hospital service to gainxperience in all 3 methods of angle fracture treat-ent. Three factors were used in making this deci-

ion: isolated fractures of the mandibular angle arextremely uncommon (average 19/year at Parklandospital); 2 of the treatment arms are not commonlyerformed in our hospital (nonrigid fixation and 2iniplates), and senior residents rotate through thisospital every 3 months. Therefore, the average resi-ent only treated approximately 6 patients in thetudy, and by sequential assignment of treatments, itould be guaranteed that each resident would treatpproximately 2 patients in each treatment group.onrandomized assignment, although more difficult

o implement in an unbiased manner than random-zed assignment, is still a legitimate method of assign-

, Preoperative panoramic radiograph; B, immediate postoperativeling; D, photograph at 4 weeks showing abscess spontaneouslyshowing radiolucency around one of the bone screws in the loweric radiograph taken after hardware removal and sequestrectomyen 4 weeks later. The patient had good occlusion and no mobility

illofac Surg 2010.

lates. Ag swelweeksnoramph tak

ng patients to study groups in some circumstances.45

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he main advantage to randomization is that variableshat might affect treatment outcomes should bequally distributed to all treatment groups. The resultsf comparison of the demographic characteristics ofhe 3 treatment groups in this study showed no sta-istically significant difference among them, indicat-ng that although not ideal, the assignment of treat-

ent groups fulfilled the desire for resident educations well as comparability of the demographics of thereatment groups.

There have been studies on the treatment of frac-ures of the mandible that have shown that operatorxperience is an important factor in treatment out-omes.4,46,47 There is no question that experiencedurgeons can treat injuries faster and perhaps withess surgical trauma that those who are less experi-nced. An important consideration about operator ex-erience, however, is that it takes much less experienceo become adept at using a single miniplate than thether techniques. The main difference in the treatmentariables for the current sample was the duration ofurgery and the ease with which a single miniplateas applied when compared with the internal wire

nd double miniplate groups. A single miniplate, fromncision to last suture, could be placed in an averagef 23.5 minutes, and its placement was never rated asdifficult” by the surgeons. In fact, it was rated “someifficulty” in only 5 cases. All other cases were rateds “simple.” Two miniplates took an average of 37inutes to apply and was rated “difficult” in 9 cases

nd “somewhat difficult” in 27 cases—as many casess were rated “simple.” Placement of the second platet the inferior border is a more difficult task andequires more experience to become facile. This un-oubtedly comes from the need to use a trochar topply the plate at the lower border, where access andisibility are much more limited. Without a clear ben-fit to the second plate, taking the time and sufferinghe aggravation of placing it can be questioned. Therere also additional costs incurred using a second bonelate, including not only the cost of the plate and 4ore screws but the additional time to place it.The finding that a single miniplate outperforms 2

lates defies logic because conventional wisdomould indicate that more stable fixation should pro-

ide fewer complications. All biomechanical tests per-ormed to date indicate that 2 plates are more stablehan 1.17,18,48-52 However, the results of this investi-ation corroborate the findings of previous prospec-ive studies38-41 and the many retrospective noncom-arative studies14,16,25,29,31-37 that have found that theomplication rate is as low or lower using a singleiniplate to treat angle fractures when compared with

sing 2 miniplates. This indicates that biomechanics,
lthough important, is not the only factor to be consid-
red when selecting internal fixation schemes for frac-ures through the mandibular angle.

The outcomes among the 3 groups presented herere variable. At the last visit, there were not many dif-erences between the groups. Most had good occlusion,ood mandibular mobility, similar neurosenory func-ion, acceptable radiographic reductions, and so forth.uriously, the wire fixation group had some mobility of

he segments to bimanual manipulation at last visit, buthe incidence of malocclusion was low, similar to thether groups. It is likely that the mobility would dimin-

sh in time as the fracture further solidifies. Overall, theain problem using internal wire fixation or 2 bonelates was the high incidence of wound problems, in-luding dehiscence, infection, exposed hardware andone, and so forth. This was strikingly dissimilar to theingle miniplate group, who had only 2 cases of woundroblems. Most of the cases of wound problem in allroups required surgical intervention to control infec-ion, debride devital bone, remove loose hardware,mong other indications. Aside from the inconvenienceo the patient, there was a cost to additional interven-ion. The advantage of placing hardware at the superiororder is that it is more readily retrievable in the clinicetting. The group treated with 2 miniplates more com-only required a general anesthetic in the operating

oom to retrieve the hardware or treat the infection.his adds substantially to the cost of treating the com-lication.In summary, the use of a single miniplate was asso-

iated with fewer complications than if 2 plates weresed or if an interosseous wire and MMF were em-loyed. It was also found to be the easiest internalxation scheme to master. Fortunately, the techniquehat offers the best results is also that which is theimplest to learn.

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ellis mandile (1)

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