CRANIOMAXILLOFACIAL TRAUMA

What Method for Management of Unilateral

Mandibular Angle Fractures Has the Lowest
Rate of Postoperative Complications?
A Systematic Review and Meta-Analysis
Essam Ahmed Al-Moraissi, BDS, MSc, PhD,* and Edward Ellis III, DDS, MSy
Purpose: The aim of the present study was to determine which method for internal fixation through a
transoral approach has the lowest complication rate for patients with mandibular angle fractures (MAFs).
Materials and Methods: To address our study purpose, we designed and implemented a systematic
review with meta-analysis. To identify the studies to include in the review, a comprehensive electronic
search without date or language restrictions was performed in April 2014. The inclusion criteria were
studies of humans, including randomized or quasi-randomized controlled trials (RCTs), controlled clinical
trials (CCTs), and retrospective studies, with the aim of comparing fixation techniques (1 vs 2 miniplates,
external oblique ridge vs lateral border miniplate placement, and geometric vs conventional miniplate) in
the management of MAFs. The incidence of postoperative complications was analyzed. Only those studies
in which a transoral approach had been used (with or without transbuccal instrumentation) were selected.
Results: A total of 20 publications were included: 9 RCTs, 3 CCTs, and 8 retrospective studies. Eight
studies had a low risk of bias, 11 studies a moderate risk of bias, and 1 a high risk of bias. A statistically sig-
nificant difference was found between a single superior border miniplate and the use of 2 miniplates. The
cumulative odds ratio (OR) was 0.63, indicating that the use of 1 miniplate in MAF fixation decreased the
risk of postoperative complications by 37% compared with using 2 miniplates. Comparing a miniplate
placed on the external oblique ridge to one placed on the lateral surface of the mandible resulted in a
cumulative OR of 2.10, indicating that the use of the transbuccal miniplate decreased the risk of postoper-
ative complications by 110% compared with a miniplate placed on the external oblique ridge. Comparing
geometric and standard miniplates, the OR was 0.29, indicating that the use of a geometric miniplate
decreased the risk of postoperative complications by 71% compared with using conventional miniplates.
Conclusions: The results of the meta-analysis have shown that the use of 1 miniplate is superior to using 2
in reducing the incidence of postoperative complications in the management of MAFs. In addition, our results
showed that the transbuccally placed lateral miniplate was better at reducing the incidence of postoperative
complications than one placed on the external oblique ridge using a transoral approach. Finally, geometric
miniplates performed better than conventional miniplates in reducing postoperative complications.
Ó 2014 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 72:2197-2211, 2014

Mandibular angle fractures (MAFs) are the most com- MAFs can be defined as a fracture line that starts in
mon mandibular fracture in developed countries, the area where the anterior border of the mandibular
accounting for 30% of all mandibular fractures.1 ramus meets the body of the mandible, usually in the

*PhD Student, Department of Oral and Maxillofacial Surgery,
Cairo University Faculty of Oral and Dental Medicine, Cairo, Egypt;
Lecturer, Department of Oral and Maxillofacial Surgery, Thamar
University Faculty of Dentistry, Thamar, Yemen.
yProfessor and Chair, Department of Oral and Maxillofacial
Surgery, University of Texas Health Science Center, San
Antonio, TX.
Conflict of Interest Disclosures: None of the authors reported any
disclosures.
Address correspondence and reprint requests to Dr Al-Moraissi:
Department of Oral and Maxillofacial Surgery, Thamar University
Faculty of Dentistry, Thamar, Yemen; e-mail: dr_essamalmoraissi@
yahoo.com
Received April 20 2014
Accepted May 21 2014
Ó 2014 American Association of Oral and Maxillofacial Surgeons
0278-2391/14/00576-X$36.00/0
http://dx.doi.org/10.1016/j.joms.2014.05.023

2197
2198
region of the third molar. It will extend inferiorly
through the inferior border or, on occasion, extend
posteriorly, through the region of the gonial angle. If
the third molar is present, it could be located any-
where along the root of this tooth. Sometimes, the
fracture will be along the distal root, with the tooth re-
maining within the distal segment of the mandible.2
The posterior position and biomechanics of the
angle has made the treatment of fractures in this region
difficult, and, not surprisingly, MAFs have generated
more complications than other mandibular fractures,
with an incidence ranging from 0 to 32%.3,4 Because
teeth might not be present to prevent the rotation of
the proximal segment superiorly, open reduction
and internal fixation has routinely been required for
MAFs. A variety of techniques have been used for
internal fixation of MAFs. These techniques have
included wire osteosynthesis, a single superior
border miniplate (2.0 mm), a single inferior border
plate (2.3 or 2.7 mm), 2 plates (1 at the superior
border and 1 at the inferior border), geometric plates,
or a lag screw.5 Since the introduction of the technique
for miniplate fixation of MAFs by Michelet et al,6 a large
amount of controversy has ensued regarding the most
appropriate method.
Studies have shown that a single miniplate can be
placed at the superior border along the lateral aspect
of the mandible to act as a tension band.6,7 This has
had a relatively low complication rate of 12 to 16%.8,9
Several studies have shown no increased risk of
complications between the use of 1 plate and 2 plates;
however, other studies have shown a decreased rate
of complications with the use of 1 superiorly placed
noncompression miniplate.10-13 However, in vitro
studies have demonstrated that 2-plate fixation is a
more stable method, with lower stress at the fracture
site compared with a single superior border plate placed
in the Champy style.14 Choi et al14,15 reported a low
complication rate with 2 noncompression miniplates,
with only 4 complications in 40 patients. In contrast,
Ellis and Walker16 found that the use of two 2.0-mm non-
compression miniplates had an unacceptable complica-
tion rate of 28%. Schierle et al17 reported no difference
in outcomes between the use of a single plate versus
2 miniplates, but Levy et al18 found that 2 plates were
better than 1.
The use of 3-dimensional (3D) strut plates has been
one of the methods of fixation to challenge the Champy
technique for MAF fixation, with an increasing number
of clinical studies.19 The 3D plates can be considered a
2-plate system, with 2 miniplates joined by intercon-
necting crossbars.20 Their shape is based on the princi-
ple of the quadrilateral as a geometrically stable
configuration for support.21 Because the screws are
arranged in the configuration of a box on both sides
of the fracture, a broad-band platform is created,
FIXATION METHODS FOR MANDIBULAR ANGLE FRACTURES
increasing the resistance to twisting and bending of
the long axis of the plate.22
The purpose of the present study was to determine
which method for internal fixation using a transoral
approach would have the lowest complication rate
for patients with MAFs. A secondary aim was to pro-
vide scientific data that would enable surgeons to
make an evidence-based decision on which method
would be the best.
Materials and Methods
SEARCH METHODS FOR STUDY IDENTIFICATION
The present systematic review and meta-analysis was
conducted according to the preferred reporting items
for systematic reviews and meta-analyses (PRISMA)
Equity 2012 checklist.23 A comprehensive electronic
search without date or language restrictions was per-
formed in April 2014 using the following electronic da-
tabases: PubMed, Cochrane Database of Systematic
Reviews, the Cochrane central register of controlled tri-
als, EMBASE, MEDLINE, CINAH, and the Electronic Jour-
nal Center, using 1 or combination of the following
search terms: ‘ randomized controlled trial [1 vs 2 mini-
plate in mandibular angle fractures]’’ AND/OR ‘ transoral
versus transbuccal miniplate in mandibular angle frac-
tures’’ AND/OR ‘ single versus double miniplate in
mandibular angle fractures,’’ ‘ superior versus inferior
border miniplate in mandibular angle fractures,’’
‘ Champy technique,’’ ‘ postoperative complication in
mandibular angle fractures,’’ ‘ osteosynthesis of mandib-
ular angle fractures,’’ ‘ linea oblique versus lateral or
ventral plate,’’ ‘ ridge plate versus lateral plate,’’ ‘ three-
dimensional versus conventional miniplate,’ ‘ matrix
miniplate,’’ ‘ 3D strut miniplate,’’ and ‘ geometric mini-
plate in mandibular angle fractures.’’
A manual search of oral and maxillofacial surgery–
related journals, including the International Journal
of Oral and Maxillofacial Surgery, British Journal
of Oral and Maxillofacial Surgery, Journal of
Oral and Maxillofacial Surgery, Oral Surgery, Oral
Medicine, Oral Pathology, Oral Radiology and
Endodontology, Journal of Cranio-Maxillofacial
Surgery, Journal of Craniofacial Surgery, Archives
of Otolaryngology–Head and Neck Surgery, and
Journal of Maxillofacial and Oral Surgery, was
also performed.
The reference list of the identified studies and the rele-
vant reviews were also evaluated for possible additional
studies. Moreover, online databases providing informa-
tion about clinical trials in progress were checked
(clinicaltrials.gov; available at: www.centerwatch.
com/clinicaltrials; www.clinicalconnection.com). Any
randomized or quasi-randomized controlled trials
(RCTs), controlled clinical trials (CCTs), or retrospec-
tive studies with the aim of comparing postoperative
AL-MORAISSI AND ELLIS III
complications between or among fixation techniques
(eg, 1 vs 2 miniplates, external oblique ridge vs lateral
miniplates, and geometric vs conventional miniplates)
in the management of MAFs were included. The exclu-
sion criteria were case reports, technical reports, animal
studies, in vitro studies, review reports, studies using
bioabsorbable materials, and studies that included in-
fected and/or comminuted MAFs, fractures in edentu-
lous mandibles, and pediatric MAFs.
DATA COLLECTION PROCESS
We carefully assessed the eligibility of all studies
retrieved from the databases. In the final analysis, the
following data were extracted (when available) from
the included studies: authors, year of publication,
study design, number of patients, gender, mean age
in years, follow-up period, fixation methods, postoper-
ative intermaxillary fixation, operative time (mean in
minutes), and associated fractures. We reached out
to the authors of the studies to retrieve possible
missing data.
RISK OF BIAS IN INDIVIDUAL STUDIES
A methodologic quality rating was performed of the
included studies. We combined the proposed criteria
from the Meta-analysis of Observational Studies in Epide-
miology statement,24 Strengthening the Reporting of
Observational Studies in Epidemiology statement,25
and PRISMA,26 to verify the strength of the scientific ev-
idence in clinical decision-making.
The classification of the risk of bias potential for
each study was determined using 5 criteria: random se-
lection in the population, definition of inclusion and
exclusion criteria, report of losses to follow-up, vali-
dated measurements, and statistical analysis. A study
that included all 5 criteria was classified as having a
low risk of bias. A study that did not include 1 of these
criteria was classified as having a moderate risk of bias.
When 2 or more criteria were missing, the study was
considered to have a high risk of bias.
META-ANALYSIS
Meta-analyses were conducted only for studies
with similar comparisons, reporting the same outcome
measures. For binary outcomes, we calculated a stan-
dard estimation of the odds ratio (OR) using the random
effects model if heterogeneity was detected; otherwise,
a fixed effect model with 95% confidence intervals
(CIs) was performed. Weighted mean differences were
used to construct forest plots of continuous data.
The data were analyzed using the statistical software
Review Manager, version 5.2.6 (The Nordic Cochrane
Centre, The Cochrane Collaboration, Copenhagen,
Denmark, 2012).
2199
ASSESSMENT OF HETEROGENEITY
The significance of any discrepancies in the estimates
of the treatment effects of the different trials was
assessed using Cochran’s test for heterogeneity and
the I2 statistic, which describes the percentage of total
variation across studies resulting from heterogeneity
rather than chance. Heterogeneity was considered sta-
tistically significant if P < .1. A rough guide to the inter-
pretation of I2, given in the Cochrane Handbook,27 is as
follows: 1) from 0 to 40%, the heterogeneity might not
be important; 2) from 30 to 60%, it might represent
moderate heterogeneity; 3) from 50 to 90%, it might
represent substantial heterogeneity; and 4) from 75 to
100%, considerable heterogeneity is present.
INVESTIGATION OF PUBLICATION BIAS
A funnel plot (plot of effect size vs standard error)
was drawn. Asymmetry of the funnel plot could indi-
cate a publication bias and other biases related to sam-
ple size, although the asymmetry could also represent a
true relationship between the trial size and effect size.
SENSITIVITY ANALYSIS
If the included studies were sufficient, we conduct-
ed a sensitivity analysis to assess the robustness of the
review results by repeating the analysis with the exclu-
sion of studies with a high risk of bias.
Results
STUDY SELECTION
The study screening process is summarized in
Figure 1. The electronic search resulted in 526 entries.
Of the 526 studies, 88 were excluded because they
were in vitro studies. After the initial screening of
the titles and abstracts, 336 studies were excluded
because they were off topic. The full-text reports of
the remaining 102 studies led to the exclusion of 82
because they did not meet the inclusion criteria.
Thus, a total of 20 publications10-12,17,18,21,28-41 were
included in the review. Of the 20 publications, 10
studies10-12,17,18,28,30,31,34,35 had compared 1 and 2
miniplates for MAF fixation, and 5 studies29,31-33,36
had compared transoral external oblique ridge
placement of a miniplate with transbuccal placement
of a miniplate along the lateral cortex. Finally, 6
studies21,37-41 had compared the use of geometric
and conventional miniplates for MAF fixation.
CHARACTERISTICS OF INCLUDED STUDIES
Detailed characteristics of the included studies are
listed in Table 1. Nine RCTs,10,12,17,29,32,36,38,40,41
three CCTs,30,34,35 and eight retrospective
studies11,18,28,31,33,37,39,40 were included in the meta-
analysis and critical appraisal. A total of 959 patients
2200
FIGURE 1. Study screening process. MAFs, mandibular angle fractures.
Al-Moraissi and Ellis III. Fixation Methods for Mandibular Angle Fractures. J Oral Maxillofac Surg 2014.
were enrolled in 10 studies10-12,17,18,28,30,31,34,35; 1
compared 1 superior miniplate on the external
oblique ridge (n = 466) to 2 miniplates (n = 493; 1
superior miniplate on the external oblique ridge and
1 at the inferior border of mandible). A total of 1,068
patients were included in 5 studies29,31-33,36 that had
compared 1 miniplate placed transorally along the
external oblique ridge (n = 610) with 1 miniplate
placed along the lateral aspect of the superior border
using transbuccal trocar instrumentation (n = 458).
Finally, a total of 309 patients were enrolled in 6
studies21,37-41 that had compared geometric (n =
197) and conventional (n = 112) miniplates.
Concerning the surgical technique in the 1 versus 2
miniplate comparisons, for all patients allocated to the
single miniplate group, a 2.0-mm titanium miniplate
was placed using an intraoral approach at the external
oblique ridge with 2 monocortical screws on either
side of the fracture line (Fig 2). In the 2-miniplate
group, the patients had had a second miniplate in-
serted near to the inferior border of mandible with
transbuccal trocar instrumentation (Fig 3).
FIXATION METHODS FOR MANDIBULAR ANGLE FRACTURES
In transorally placed versus transbuccally placed
single miniplate comparison, a 4-hole centrally spaced
or nonspaced miniplate was placed either on the
external oblique ridge using a transoral approach
(Fig 1) or laterally using a combined oral and transbuc-
cal trocar approach. In both groups, 2.0-mm mono-
cortical screws were placed (Fig 4).
Concerning the 3D miniplate group (Fig 5), a rectan-
gular 3D miniplate was used in 3 studies21,37,38 and a
curved 3D miniplate in 3 studies.39-41 The number of
holes in the 3D miniplates varied widely among the
studies. Four studies used a combination of an
intraoral approach with the use of a transbuccal
trocar.21,38-40 Two studies exclusively used the
intraoral approach without a transbuccal trocar.37,41
Four studies37-39,42 provided information about the
mean operation time.
RISK OF BIAS WITHIN STUDIES
Concerning the quality assessment of the included
studies, 8 studies10,12,21,29,32,36,38,41 showed a low
 AL-MORAISSI AND ELLIS III
Table 1. COMPARISON AMONG FIXATION METHODS FOR MAFS

Mean
Study Gender Age Range Patients* Follow-Up MAF Fixation Postoperative Operative Surgical Associated
Investigators Year Design (M/F) (Average) (yrs) (n) Period Methods MMF (n) Time (min) Approach Fractures

Schierle et al17 1997 RCT NM NM G1: 16 NM G1: single 2-mm NM NM G1: IO G1: 3
G2:15 miniplate G2: IO/TB G2: 4
G2: two 2-mm (5 PS, 3 condyle)
Miniplates
Siddiqui et al12 2007 RCT G1,G2: 75/10 G1,G2: 17-57 G1: 36 12 wk G1: single* 2-mm No NM G1: IO NM
G2: 26 miniplate G2: TB
G2: two 2-mm
miniplates
Mehra et al28 2008 RS NM G1,G2: G1: 76 8-64 wk G1: single 2-mm G1: MMF, 2 wk, G1: 34 G1: IO/TB NM
17-57 (24.8) G2: 57 (12.3 wk) miniplate elastic, 4 wk G2: 119.6 G2: EO
G2: two 2-mm G2: MMF, 1 wk,
miniplates elastic 1- 4 wk
Sugar et al29 2009 RCT G1: 52/4 G1: 16-52.08 G1: 56 1 wk, 1 mo, G1: single 2-mm NM NM G1: IO NM
G3: 80/4 (26.64) G3: 84 3 mo miniplate G3: TB/IO
G3: 17.02-68.11 G3: single 2-mm
(25.86) miniplate
Danda10 2010 RCT G1: 21/6 G1: 18-43 (32.4) G1: 27 1, 2, 4, G1: single* 2-mm 2 wk, arch bars NM G1: IO No
G2: 23/4 G2: 21-49 (29.6) G2: 27 6 wk miniplate for 4 wk G2: TB
G2: two 2-mm
miniplates
Seemann et al11y 2010 RS G1,G2: 295/63 Men: 29.67 G1: 95 NM G1: single 2-mm G1: 6.06% NM NM G1: 3.70%
Women: 49.07 G2: 170 miniplate G2: 4.46% G2: 6.16%
G2: two 2-mm
miniplates
Ellis30 2010 CCT G1: 55/7 G1: 13-51 (28.5) G1: 62 $6 wk G1: single 2-mm No G1: 23.5 G1: IO No
G2: 55/8 G2: 17-54 (27.8) G2: 63 miniplate G2: 37 G2: IO/TB
G2: two 2-mm
miniplates
Kumar et al31z 2011 RS G1,G2: 63/18 G1,G2: G1: 35 3 mo G1: single NM NM G1: IO NM
16-62 (26.6) G2: 33 anterior plate G2: EO
G3: 15 G2: 2 plates G3: IO/TB
G3: single ventral
plate
Laverick et al32 2012 RCT NM NM G1: 137 40 wk G1: single 2-mm NM G1: 55 G1: IO NM
G3: 124 miniplate G3: 60 G3: TB
G3: single 2-mm
miniplate
Wan et al33 2012 RS G1: 370/0 G1: 28.3 G1: 370 NM G1: single 2-mm NM NM G1: IO NM
G3: 199/0 G3: 29.1 G3: 199 miniplate G3: TB

2201
G3: single 2-mm
miniplate
 2202
Table 1. Cont’d

Mean
Study Gender Age Range Patients* Follow-Up MAF Fixation Postoperative Operative Surgical Associated
Investigators Year Design (M/F) (Average) (yrs) (n) Period Methods MMF (n) Time (min) Approach Fractures

Yazdani et al34 2013 CCT G1,G2: 73/14 G1,G2: 16-66 G1: 45 1, 2 wk, 2, 3, 6, G1: single 2-mm 1 wk NM G1: IO No
G2: 42 12 mo miniplate G2: IO+TB
G2: two 2-mm
miniplates
Cillo et al35 2014 CCT G1,G2: 31/2 G1,G2: 18-48 G1: 33 8 wk G1: single 2-mm No NM G1: IO No
(25.2) G2: 33 miniplate G2: IO+TB
G2: two 2-mm
miniplates
Pattar et al36x 2013 RCT G1,G2,G3: NM G1: 12 6-24 mo G1: 1 superior G1 = 3; G2 = 1; NM G1: IO No
G3: 8 border plate G3 = 4 G3: TB
G3: 1 ventral plate patients: IMF G4: EO
G4: 1 inferior elastic for 1 wk
border plate
Levy et al18 1991 RS G1,G2: 52/9 G1,G2: 18-47 G1: 19 1, 2, 4, 6, G1: single 2-mm G1: 6; 3 left, 4 NM G1: IO G1: 9k
(28.6) G2: 22 12 wk miniplate right; average G2: IO+TB G2: 22k
G2: two 2-mm IMF, 24 days
miniplates G2: 14; 11 left, 3
right IMMF,

FIXATION METHODS FOR MANDIBULAR ANGLE FRACTURES

25.3 days
ofer et al37*
H€ 2012 RS G1,G5: 52/8 G1,G5: G1: 30 7, 14, 28 days G1: Single 2.0- NP G1: 89 IO Angle (n = 60),
15-73 (31.1) G5: 30 3, 6, 12 mo mm miniplate G5: 81 bodyy (n = 25),
(n = 30) ascending
G5: 3D 2.0-mm ramusy (n = 5)
miniplate
Singh et al38* 2012 RCT G1,G5: G1,G5: 17-46 G1: 10 1, 4, 8, 12 wk G1: 2.0-mm G1: 17 G1: 44 IO or IO+TB Angle (n = 20),
46/4 (30.4) G5: 10 miniplate G2: G5: 8 G5: 57 parasymphysis
3D 2.0-mm 6- (n = 35),
hole 3D symphysis (n =
miniplate 1)
Guy et al39 2013 RS G1,G5: 84/6 G1,G5: 14-58 (28) G1: 22 8-308 days G1: one or two G1: 14; 64% G1: 232 IO+TB (G1, G2), Angle (n = 96),
G5: 68 (mean 47; G1) 2.0-mm 4-hole G5: 35; 51% G5: 219 EO (9% in G1) parasymphysis
2-355 days (mean miniplate n = (n = 41), body
55; G2) 22z (n = 11),
G5: curved 2.0- condyle (n =
mm 8-hole 3D 5), coronoid
miniplate (n = 2), ramus
(n = 6)
 Moore et al40

AL-MORAISSI AND ELLIS III

2013 RS NM G1,G5: NM (31) G2: 33 NM G1: single 2.0- NP NM IO+TB Angle (n = 106),
G5: 73 mm (n = 33) parasymphysis
G5: single curved (n = 11), body
2.0-mm 8-hole (n = 51)
3D miniplate
Vineeth et al21 2013 RCT G1,G5: 17/3 G1,G5: 19-51 G1: 10 1 day G1: Single 2.0- G1: 3 NM IO+TB Angle (n = 20),
(NM) G5: 10 1 wk mm miniplate G2: 1 additional
1 mo G2: Single fracturesy (n =
3 mo rectangular 9; G1, n = 5;
2.0-mm 6- or 8- G2, n = 4)
hole 3D
miniplate
Xue et al41 2013 RCT G1,G5: 13/0 G1,G5: NM (NM) G1: 7 1-2 wk G1: single 2.0- NP G1: 42 IO Angle (n = 13),
G5: 6 4-6 wk mm miniplate G5: 102 parasymphysis
6 mo G5: single curved (n = 8),
2.0-mm 10- subcondylar
hole 3D (n = 1)
miniplate

Abbreviations: CCT, controlled clinical trial; EO, extraoral; M/F, male: female; G1, 1 transoral miniplate on external oblique ridge; G2, 2 miniplates (1 as G1, second plate on lateral
surface of the mandible); G3, 1 transbuccal miniplate; G4, 1 plate at inferior border; G4, lag screw; G5, geometric plate; IO, intraoral; M, male; MAF, mandibular angle fracture;
MMF, maxillomandibular fixation; NM, not mentioned; NP, not performed; PS, parasymphyseal; RS, retrospective study; RCT, randomized controlled trial; TB, transbuccal.
* G1, a single 2-mm miniplate placed transorally on external oblique ridge; G2, two 2-mm miniplates, 1 plate placed the same as for G1 and 1 plate inserted transbuccally, as near
as possible to the inferior border.
y For both G1 and G2, MMF and associated fractures reported as percentages.
z Thirty-three bilateral mandibular angle fractures, 1 side fixed by 2 superior and inferior miniplates and 1 side with 1 superior miniplate.
x This study consisted of 3 groups: 1 superior miniplate (transoral), 2 miniplates (EO), and 1 miniplate (IO and TB).
k Consisted of 3 groups: G1, n = 15; G2, n = 9; G5, n = 21.
Al-Moraissi and Ellis III. Fixation Methods for Mandibular Angle Fractures. J Oral Maxillofac Surg 2014.

2203
2204
FIGURE 2. Illustration showing an angle fracture with a single min-
iplate placed along the external oblique ridge (Champy et al7).
Note that it is located medial to the anterior border of the ramus pos-
teriorly and along the external oblique ridge anteriorly. This plate
was placed using a transoral approach.
Al-Moraissi and Ellis III. Fixation Methods for Mandibular Angle
Fractures. J Oral Maxillofac Surg 2014.
risk of bias, 11 studies11,17,18,28,30,31,33-35,37,39 showed
a moderate risk of bias, and 1 study40 showed a high
risk of bias. The scores are summarized in Table 2.
RESULTS OF INDIVIDUAL STUDIES
One Versus Two Miniplates
Ten studies,10-12,17,18,28,30,31,34,35 comparing 1 and
2 miniplates, assessed the incidence of postoperative
complications. A significant difference was found
for postoperative hardware failure and scarring but
not for infection, wound dehiscence, hardware
failure malocclusion, nonunion, or paresthesia.
The cumulative overall analysis of all complications
revealed a statistically significant advantage for the
1-miniplate technique when the incidence of all post-
operative complications was considered (OR 0.63,
FIGURE 3. Illustration showing an angle fracture treated with 2
miniplates, 1 along the external oblique ridge and 1 along the
buccal surface of the inferior border. The inferior plate was placed
using transbuccal trocar instrumentation.
Al-Moraissi and Ellis III. Fixation Methods for Mandibular Angle
Fractures. J Oral Maxillofac Surg 2014.
FIXATION METHODS FOR MANDIBULAR ANGLE FRACTURES
FIGURE 4. Illustration showing a miniplate placed along the supe-
rior aspect of the lateral cortex of the mandible. This plate was
placed using transbuccal trocar instrumentation.
Al-Moraissi and Ellis III. Fixation Methods for Mandibular Angle
Fractures. J Oral Maxillofac Surg 2014.
95% CI 0.48 to 0.83, P = .001). The test of heterogene-
ity among all studies showed homogeneity (c2 =
44.11, df = 33, P = 0.09; I2 = 292%), as did the test
for subgroup differences (inconsistency across the
subgroups; c2 = 11.60, df = 7, P = .11; I2 = 39.7%).
The cumulative OR was 0.63, indicating that the use
of 1 miniplate in the fixation of MAFs decreased the
risk of postoperative complications by 37% compared
with using 2 miniplates (Fig 6).
Transoral Versus Transbuccal Miniplates
Five studies,29,31-33,36 comparing transorally placed
miniplates along the external oblique ridge and
miniplates placed along the lateral cortex using
transbuccal instrumentation, reported the incidence
of postoperative complications. A significant dif-
ference was seen for postoperative infection, wound
dehiscence, and hardware failure but not for
FIGURE 5. Illustration showing a 3-dimensional geometric plate
placed along the lateral aspect of the mandible. This plate was
placed using transbuccal trocar instrumentation.
Al-Moraissi and Ellis III. Fixation Methods for Mandibular Angle
Fractures. J Oral Maxillofac Surg 2014.
AL-MORAISSI AND ELLIS III 2205

Table 2. CRITICAL APPRAISAL OF INCLUDED STUDIES (QUALITY ASSESSMENT)

Defined Inclusion Loss of

Random Selection or Exclusion Follow- Validated Statistical Estimated Potential
Investigator Year in Population Criteria Up Measurement Analysis Risk of Bias

Levy et al18 1991 No Yes Yes Yes Yes Moderate

Schierle et al17 1997 Yes Yes Yes Yes No Moderate
Siddiqui et al12 2007 Yes Yes Yes Yes Yes Low
Mehra et al28 2008 No Yes Yes Yes Yes Moderate
Sugar et al29 2009 Yes Yes Yes Yes Yes Low
Danda10 2010 Yes Yes Yes No Yes Low
Seemann et al11 2010 No Yes Yes Yes No Moderate
Ellis30 2010 No Yes Yes Yes Yes Moderate
Kumar et al31 2011 No Yes Yes Yes Yes Moderate
Laverick et al32 2012 Yes Yes Yes Yes Yes Low
Wan et al33 2012 No Yes Yes Yes Yes Moderate
Yazdani et al34 2013 No Yes Yes Yes Yes Moderate
Potter et al36 2013 Yes Yes Yes Yes Yes Low
H€ofer et al37 2012 No Yes Yes Yes Yes Moderate
Singh et al38 2012 Yes Yes Yes Yes Yes Low
Guy et al39 2013 No Yes No Yes Yes Moderate
Moore et al40 2013 No Yes No No Yes High
Vineeth et al21 2013 Yes Yes Yes Yes Yes Low
Xue et al41 2013 Yes Yes Yes Yes Yes Low
Cillo et al35 2014 No Yes Yes Yes Yes Moderate
Al-Moraissi and Ellis III. Fixation Methods for Mandibular Angle Fractures. J Oral Maxillofac Surg 2014.

malocclusion, paresthesia, or nonunion. The cumula- the incidence of postoperative complications

tive overall analysis of all complications revealed
statistically significant superiority for the transbuccal
miniplate technique when the incidence of all
postoperative complications was considered (OR 2.10,
95% CI 1.768 to 2.62, P = .00001). The test of
heterogeneity among all studies showed homogeneity
(c2 = 22.49, df = 17, P = .17; I2 = 24%), as did the test
for subgroup differences (inconsistency across the
subgroups; c2 = 16.747, df = 5, P = .006; I2 = 69.3%).
The cumulative OR was 2.10, indicating that the use
of 1 miniplate on the lateral cortex placed with
transbuccal trocar instrumentation decreased the risk
of postoperative complications by 110% compared
with using transorally placed miniplates along the
external oblique ridge. The OR of 2.10 indicates that
patients with MAFs who were treated with a
transorally placed miniplate along the external oblique
ridge were 2.10 times more likely to develop a
postoperative complication than were patients with
MAFs treated by a miniplate on the superior aspect of
the lateral cortex placed with transbuccal trocar
instrumentation (Fig 7).
Geometric Versus Conventional Miniplate
Six studies21,37-41 compared geometric and con-
ventional miniplates with regard to postoperative
complications. A significant decrease was seen in
using geometric miniplates than with conventional
miniplates (OR 0.29, 95% CI 0.16 to 0.55, P = .0001).
The OR was 0.29, indicating that the use of the
geometric miniplates for MAF fixation decreased the
risk of postoperative complications by 71% compared
with the use of conventional miniplates (Fig 8).
SENSITIVITY ANALYSIS AND PUBLICATION BIAS
The cumulative analysis after the exclusion of the
studies with a high risk of bias(1 study40) did not
change the overall main results. The funnel plot did
not show any noticeable asymmetry, indicating
absence of publication bias (Fig 9).
Discussion
The management of MAFs has been controversial
because of the anatomic relations and complex biome-
chanical aspects of the mandibular angle, including a
thin cross-sectional area, abrupt change in the curva-
ture, attachment of the masticatory muscles, and the
presence of third molars.42 The debate has become
even more heated since the evolution of rigid internal
fixation and the ability to provide adequate stability of
the fractured segments.2,5 Postoperative complications
associated with MAFs have been common. The variety
of reported complications has most likely been
2206 FIXATION METHODS FOR MANDIBULAR ANGLE FRACTURES

FIGURE 6. Forest plot for the effect of intervention, 1 versus 2 miniplates.

Al-Moraissi and Ellis III. Fixation Methods for Mandibular Angle Fractures. J Oral Maxillofac Surg 2014.
AL-MORAISSI AND ELLIS III 2207

FIGURE 7. Forest plot for the effect of intervention, transoral versus transbuccal miniplates.
Al-Moraissi and Ellis III. Fixation Methods for Mandibular Angle Fractures. J Oral Maxillofac Surg 2014.

related to the variations in the fixation method, patient- The purpose of the present study was to determine
related factors, and how these 2 variables interact with the best method for transoral management of MAFs
the complex biomechanics of the mandibular angle.5 with the lowest rate of postoperative complications.
2208 FIXATION METHODS FOR MANDIBULAR ANGLE FRACTURES

FIGURE 8. Forest plot for the effect of intervention, geometric versus conventional miniplates.
Al-Moraissi and Ellis III. Fixation Methods for Mandibular Angle Fractures. J Oral Maxillofac Surg 2014.

The results of our meta-analysis have revealed statisti-
cally significant superiority for the single-miniplate
technique compared with the 2-miniplate technique
with regard to the incidence of postoperative compli-
cations (P = .0001).
In vitro experiments have shown splaying of the
lower border of the mandible as a result of loading forces
close to the fracture line when only 1 miniplate has
been used. They have also shown that the application
of a second miniplate at the inferior border will provide
more stable fixation under functional loading.14,15,43-45
Combining the results of the biomechanical and
clinical studies, it becomes obvious that the bio-
mechanics are not the only factor to be considered
when selecting internal fixation schemes for fractures
through the mandibular angle.26
The high complication rate with double miniplates
could be attributed to greater periosteal and muscle
stripping in the angle region, compromising the blood
supply and healing. In addition to contamination with
oral bacteria, all these factors could increase the risk
of wound problems. The results of the present study
are consistent with previous prospective studies
showing lower complications with 1 miniplate than
with 2.11,12,17,26,31,46,47 In contrast, 3 prospective,
randomized clinical trials10,12,17 found no significant
differences between the use of 1 and 2 miniplates
in terms of postoperative infection and occlusal

FIGURE 9. Funnel plot showing no publication bias (1 vs 2 miniplates).

Al-Moraissi and Ellis III. Fixation Methods for Mandibular Angle Fractures. J Oral Maxillofac Surg 2014.
AL-MORAISSI AND ELLIS III
disturbances. Two other studies18,48 found that the use
of the 2-miniplate technique provides a lower rate of
postoperative complications than the use of only 1 mini-
plate. Thus, the published data vary concerning the use
of 1 versus 2 miniplates for MAFs.
Concerning miniplates placed transorally along the
external oblique ridge compared with those placed
laterally using transbuccal instrumentation, a signifi-
cant advantage was seen for the transbuccal lateral
miniplates (OR 2.10, P = .00001), indicating that the
use of 1 miniplate placed laterally with transbuccal
instrumentation for MAF fixation decreased the risk
of postoperative complications by 210% compared
with the use of transoral miniplates on the external
oblique ridge. This could be because of the anatomic
position of the external oblique ridge plate, which is
covered by thin soft tissue. In addition, a plate inserted
transorally will sit closer to the dentition, allowing an
easier and shorter path of bacterial pathogens to trans-
gress from the periodontal sulcus to the fixation hard-
ware. In contrast, plates fixed to the lateral aspect of
the mandible using transbuccal trocar instrumentation
will be covered by a greater bulk of soft tissue, which
might decrease the risk of dehiscence of the incision
and hardware exposure. The results of the present
study are in agreement with those from other
studies.2,29,32,45
Concerning 3D geometric versus standard mini-
plates in MAFs, an increasing number of clinical
studies have evaluated the use of 3D plates for the
treatment of MAFs. A meta-analysis of 6 studies21,37-41
comparing 3D geometric plates and miniplates
according to Champy principles was recently
published.19 The cumulative OR was 0.42, indicating
that the use of 3D geometric miniplates in MAF fixa-
tion decreased the risk of postoperative complications
by 58%. They concluded that a lower complication
rate results with 3D miniplate fixation than with stan-
dard miniplate fixation in the management of MAFs.
The results of our study are in accordance with
these findings.
One of the limitations of the present study was that 2
of the included studies11,17 did not contain isolated
MAFs. Isolated fractures of the angle are much less
common in clinical practice than the combination of
angle and contralateral body or symphysis fractures.29
It has been believed that a second fracture in the
mandible will confound the outcome data because the
fixation requirements for a double fracture will often
be different from those for an isolated fracture.49 More-
over, the real complication rates for the treatment of
MAFs can be overestimated. For instance, if malocclu-
sion is noted, it is not always possible to determine
which of the fractures might be contributing to the
malocclusion.29 Only isolated MAFs will allow us to
establish the true complication rate for these frac-
2209
tures.49 Concerning the fixation hardware, fracture of
the plate or plate exposure due to soft tissue dehiscence
might not be considered a complication in units in
which the fixation device is removed routinely after frac-
ture healing.17 Another important point is the follow-up
period, because many studies have reported only short
mean follow-up periods, although it can be difficult to
judge what is a short and what is a long period of
follow-up. Many minor complications such as fracture
or exposure of the bone plate can occur months or
even years after successful healing, but must still be
considered a complication because they will result in
surgical intervention that would not otherwise have
been necessary.19 The complication rate, therefore,
could increase with increases in the length of follow-
up.8 Many other factors can influence the incidence of
complications in patients with MAFs, such as inade-
quate immobilization of the fracture segments, a pro-
longed delay in obtaining treatment contributing to
infection, inexperienced surgeons, a lack of cooperation
from patients, trauma severity, and the presence of med-
ical co-morbidities (eg, smoking, chronic abuse of
alcohol, drugs).50
We believe that the best technique for isolated, non-
comminuted, noncomplicated MAFs will be a single
miniplate placed at superior border of external obli-
que ridge, such as advocated by Champy et al.7
Whether one chooses to apply this using a transoral
approach along the external oblique ridge or laterally
using transbuccal trocar instrumentation is the sur-
geon’s choice. With time, it is likely that more plates
placed along the external oblique ridge will require
removal than those placed laterally; however, plate
removal is a minor procedure that can be readily per-
formed in the clinic setting. When angle fractures
are associated with another mandibular fracture, the
same technique can be used for the angle, but prefer-
ably with rigid fixation of the other fracture or frac-
tures.49 Although the use of large inferior border
plates has declined, adequate bone is lacking at the
superior border, which can occur with comminuted
fractures, previously failed hardware, or pathologic
fractures, an inferior border plate, preferably a load-
bearing plate, is indicated. Such a plate is not easy to
insert transorally; thus, for difficult fractures, a transfa-
cial approach to the angle for placement of a recon-
struction bone plate will be necessary.
In conclusion, the results of our meta-analysis have
shown that the use of 1 miniplate is superior to using
2 miniplates in reducing the incidence of postopera-
tive complications in the management of MAFs. Addi-
tionally, the results of our meta-analysis found that a
transbuccally placed lateral miniplate will be better
at reducing the incidence of postoperative complica-
tions than a miniplate placed along the external obli-
que ridge (Champy) in the management of MAFs.
2210
Geometric plates have also been shown to be superior
to the use of a single miniplate in the treatment of
MAFs, but require transbuccal trocar instrumentation.
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