JOURNAL CLUB

GUIDED BY- PRESENTED BY-

Dr. Ramita Sood Dr. Itishree Kansal
H.O.D (O.M.F.S) MDS PART-1 (O.M.F.S)
Dr. Hitesh Vadera
Sr. Lecturer (O.M.F.S)
 Treatment methods for
fractures of the mandibular
angle
E. Ellis III. Treatment methods for fractures of
the mandibular angle. Int. J. Oral Maxillofac.
Surg. 1999, 28." 243-52.

Oral and Maxillofacial Surgery, The University

of Texas Southwestern Medical Center, Dallas, Texas,
USA
INTRODUCTION
 WHY IS THE ANGLE OF MANDIBLE
COMMONLY ASSOCIATED WITH
FRACTURES??
• Presence of third molars
• Thinner cross section area than the tooth
bearing region
• Biomechanically weak area “lever” area
• There are many treatment options-:

1. AO/ASIF – plate and screw fixation to provide

sufficient rigidity to prevent interfragmentary
mobility during active use of mandible
2. LUHR – large bone plates, usually
with compression, fastened with
bicortical screws
3.MICHELET ET AL. – small, easily bendable non-
compression bone plates, placed transorally
with monocortical screws

this technique sparked revolution

in treatment of facial fractures
4. CHAMPY ET AL – miniplate system
following the ideal line of
osteosynthesis
• CONTROVERSY sparked as AO/ASIF, LUHR and
RAVEH ET AL do not feel plates offer adequate
stabilization to eliminate the need for
intermaxillary fixation
• Following presents the experience of one
faculty surgeon treating mandibular angle
fractures at one institution with a persistent
patient population, using 8 different
techniques
 STUDY

• First two methods, closed reduction with or

without non-rigid fixation, and use of AO/ASIF
plates were RETROSPECTIVE
• All other were PROPECTIVE
• With the exception of extra-oral approach in
patient treated with AO/ASIF reconstruction
plate, all were intraoral with exception of
transfacial trocar instrumentation
 DATA
• AGE- avg. 27 years (mostly from 3rd to 4th
decades of life)
• SEX- predominantly male
• RACE- 50% African-Americans
30% Non-Hispanic Caucasians
20% Hispanic.
• Half were isolated angle fractures and other
half having contralateral condyle, body or
symphysis fracture
• All patients had arch • Average time between
bars injury and surgery was
attached during surgery just over 3 days
( but none with post • Only patients with
surgical IMF) minimum follow up of 6
• The arch bars were left weeks were included
into place until
functional
rehabilitation with
interincisal opening of
greater than 40 mm
• Usually 4-8 weeks post-
op.
1. Closed reduction or intraoral open
reduction and non-rigid internal
fixation
• Have become less fashionable
• “GOLD STANDARD”
• In it, retrospective study performed
• Post- surgical IMF – 6 weeks
Immediate postoperative radiograph showing angle fracture treated with
transosseous wire fixation and intermaxillary fixation. Wire was inserted
through the buccal cortex of the extraction socket
 DURING 3 YEARS PERIOD
(FOLLOW UP RANGE- 75 DAYS)
TREATMENT DONE 96 PATIENTS WITH 99 FRACTURES
( out of 99 patients)

CLOSED REDUCTION 59

OPEN REDUCTION AND TRANSOSSEOUS 34

WIRING

OPEN REDUCTION AND POSITIONAL BONE 5

PLATE

CLOSED REDUCTION WITH ADDITION OF 1

CIRCUMMANDIBULAR WIRING
 2. Extraoral open reduction and internal
fixation using the AO/ASIF reconstruction
plate
AO reconstruction is a reinforced plate that is thicker
and stronger than standard AO/ASIF bone plate

It is 3- dimensional bendable

3 screws on each side provide adequate neutralization of

functional forces in absence of compression

Useful in area of comminution, bone loss or obliquity

 Immediate postoperative radiograph showing infected angle
fracture treated with AO reconstruction bone plate. Plate was placed
through an extraoral approach. Penrose drain that was inserted during
surgery to help resolve infection can be seen. Drains were only
placed if fractures were infected
 DURATION OF 3 YEARS

ALL UNILATERAL FRACTURES

OUT OF 52 PATIENTS

31 12 9
Comminuted Oblique Simple linear
fractures fracture fracture
FOLLOWING BONE PLATE FIXATION

All dentulous patients

All fractures appeared
had reproducible
to be well reduced
occlusion in operating
and stable
room

4 pts. Had pre-existent

infection; irrigation
drains placed during
surgery
 Post operative And no damage to
radiograph within two inferior alveolar
days showed excellent neurovascular
reduction in all cases structures
4 patients had slight occlusal irregularity
requiring 2-3 weeks of elastic traction

had concomitant fractures of mandible in tooth

bearing area
making it difficult to determine
which fracture was not reduced perfectly
3. Lag screws for mandibular angle
fractures
In 1981, NIEDERDELLMANN et al. described a
method of internal fixation of mandibular
angle fractures using a single lag screw
Immediate postoperative radiograph showing angle
fracture
treated with solitary lag screw
Intra-operatively, reduction was judged In all 88 patients
excellent clinically in all patients

Supplemental methods engaged as they were In 17 out of 88 pts.

unstable to aggressive bicortical manipulation
of mandible

2.0 mm compression bone plate applied at In 3 out of 88 pts.

inferior border

Post-operative IMF used for 3-8 weeks In 14 out of 88 pts.

Follow-up was done for a mean period of 22 weeks

4. Intraoral open reduction and internal fixation
using two 2.0 mm mini-dynamic compression
plates
One AO/ASIF method to neutralize the functional forces
of an angle fracture is by restoration of tension and
compression trajectories of mandible

By application of 2 bone plates

One at the superior border One at the inferior border

Small compression plate with Large compression plate

monocortical screws with bicortical screws
Immediate postoperative radiograph showing angle fracture
treated with two 2.0 mm dynamic compression plates
Because of the difficulties encountered in

adapting and securing the larger bone plates,

the implementation of two 2.0 mm mini-

dynamic compression plates undertaken

5. Intraoral open reduction and internal fixation using
two 2.4 mm mandibular dynamic compression plates

• Because of high rates of post-surgical

complications in patients treated with two 2.0
mm mini-dynamic compression plates, standard
AO/ASIF technique of application of two
compressive bone plates specifically designed for
mandible were used
 Tension band dynamic compression plate
2.4 mm screws applied mono-cortically

Stabilization plate
Large compression plates placed with 2.4 mm
screws
Additionally, post surgical suction drainage was
used in all cases
• 65 consecutive patients with 65 fractures of the
mandibular angle were treated by open reduction
and internal fixation using two dynamic compression
plates placed through a transoral incision with
transbuccal trocar instrumentation and 2.4 mm
screws
 Immediate postoperative radiograph showing angle fracture
treated with two AO/ASIF 2.4 mm compression plates designed
for use in mandible
 6.Intraoral open reduction and internal
fixation using two non-compression
miniplates
• The previous technique showed high rate of
complication because of large bony sequestra formed
frequently.
• The reason may be devitalization of bone resulting
from compression plates
• So, patients were treated with two 2.0mm non-
compression mini plates
• Superior bone plate – placed monocortically
• Inferior bone plate- placed bicortically
• 67 consecutive patients with 69 fractures of
the mandibular angle were treated by open
reduction and internal fixation using two non-
compression miniplates placed through a
transoral incision with transbuccal trocar
instrumentation and 2.0 mm self-threading
screws
 Immediate postoperative radiograph showing angle
fracture treated with two non-compression miniplates
7. Intraoral open reduction and internal fixation
using one non-compression miniplate

• Because of the high rates of complication resulting when

two bone plates were placed, the use of a single
miniplate according to the principles of champy et al was
attempted
• OVER A PERIOD OF 2 YEARS
81 dentate pts. with non-comminuted fractures of the
mandibular angle were treated by intraoral open
reduction and internal fixation using a single four-hole
miniplate and monocortical screws
 Immediate postoperative radiograph showing angle
fracture treated with single non-compression miniplate
according to the principles of CHAMPY et al
 8. Intraoral open reduction and internal
fixation using one malleable noncompression
miniplate

• The previous technique left us with the

question

HOW MUCH FIXATION IS ADEQUATE???

LUDDE reduced the volume of the original
champy’s miniplate by half, making them
more malleable and no increase in
complication when used for mandibular
fractures was seen
How much reduction in material is
tolerable?

The purpose of this last investigation was to

prospectively evaluate the use of a thin,
malleable miniplate (Synthes Maxillofacial,
Paoli, PA, USA) that employs 1.3 mm screws
for stabilization of fractures of the mandibular
angle
• This plate was not designed for use in the
mandible, but was designed for use in the
non-load bearing regions of the midface
• Patient had a 7- hole strip of plate across
fracture with 3 monocortical screws on each
side of fracture
• No transbuccal trocar was necessary and no
bending of plates was done
• Screws were 5 mm in length
Photograph of standard 2.0 mm miniplate and 1.3 mm
miniplate used in this investigation
 1.3 mm plate is extremely thin
and malleable as shown in this photograph
46 consecutive patients with 51 fractures (5 bilateral)
were treated by this method over a period of 1.5 years
• All fractures appeared to be well reduced and
stable after plate placement.
• Postoperative radiographs taken within the
first two days showed excellent reduction in
all cases.
 DISCUSSION

• In our patient population, treatment of angle

fractures with even traditional methods closed

reduction and/or nonrigid fixation produced a

high rate of complication

• The most useful techniques in this patient population were
the use of either an extraoral open reduction and internal
fixation with the AO/ASIF reconstruction plate, or intraoral
open reduction and internal fixation using a single miniplate

• The use of the reconstruction bone plate was found to result

in few complications in a study of angle fractures by IIZUKA &
LINDQVIST
• Currently employ the latter approach with a
2.0 mm plating system for the vast majority of
cases

• An intraoral two-plate technique is not

recommended
• The results of these consecutive series of clinical
investigations performed in our hospital on a similar
patient population indicate that, contrary to popular
beliefs, up to a point
“Incidence of major complication after fracture of
angle are inversely proportional to the rigidity of
fixation applied”
• Whenever two points of fixation were used for fractures of
the angle, the complication rate was much higher than when
one point of fixation was applied
• When a second plate was applied at the inferior border, the
complications tended to be more severe, with large areas of
nonvital bone, sequestra formation and need for plate
removal, which were difficult to treat in the outpatient
setting.
• If one defines a complication as an unplanned intervention,
the two-plate techniques have a higher complication rate than
single plate techniques
• The finding that a single miniplate outperforms two plates
and other more stable forms of fixation defies logic, because
conventional wisdom would indicate that more stable fixation
should provide fewer complications.

• However , experience has been the opposite

• Use of a single miniplate was associated with much fewer

complications than if two plates were used, irrespective of
whether the two plates were compression or non-
compression plates
• All biomechanical tests performed to date indicate
that two plates are more stable than one as by
SHIERLE et al
• But biomechanics are only one factor to be
considered when treating fractures
• There are many others that may be more important
• Perhaps improved maintenance of the blood supply
to the bone because of limited dissection is one such
factor
• OPERATOR EXPERIENCE is also an important factor in
treatment

• A more important consideration about operator

experience, however, is that it takes much less experience
to become adept at using a single miniplate than the other
techniques.

Fortunately, the technique that offers the best results

is also that which is the simplest to learn
 POSITIVE ASPECTS
• Every case is having a good follow up period
• Every technique used is done in a series of
consecutive patients with consecutive period
• The same technique used can be evaluated
over duration of time so the results are
comparative
 DRAWBACKS
• The above relates the experience of one hospital,
with one patient population, treated by a large
group of residents with one faculty member.
• Whether or not the results are repeatable at
other institutions is unknown.
• Scientifically, the question about which technique
offers the best result will require a randomized
prospective study
• The patients taken in this study were random
• No significance was given to favourability or
unfavourability of fracture site
RELATED ARTICLES
 Versatility of a single upper border
miniplate to treat mandibular angle
fractures: A clinical study

P. Satish Kumaran, Lalitha Thambiah

Consultant Maxillofacial Surgeon, Consultant Dental
Surgeon, Department of Oral and Maxillofacial Surgery,
Annaswamy Mudaliar General Hospital, Bangalore

Annals of Maxillofacial Surgery | July - December 2011 |

Volume 1 | Issue 2
• Aims: The aim of this study was to determine the versatility
of the single noncompression miniplate to treat the fractures
of the mandibular angle with access via an intraoral route
• Materials and Methods: Cases of unfavorable fractures of
the mandibular angle selected for study of intraoral surgical
management of mandibular angle fractures using a single 2.0-
mm non-compression miniplate
• Statistical analysis:
 CONCLUSION
• Use of a single miniplate in the upper border could
be considered as a definitive treatment plan for
angle fractures
• Although, still controversies are present regarding
the line of treatment for angle fracture such as
location of the plates, number of plates to be used,
and the approach to be employed.
• Therefore, the study at this juncture would be an
invaluable tool for the surgeon to decide an
appropriate treatment plan
 A Review of Mandibular
Angle Fractures

Ramiro Perez, M.D., John C. Oeltjen, M.D.,

Ph.D., and Seth R. Thaller, M.D., D.M.D.,
F.A.C.S., F.A.A.P.

Craniomaxillofac Trauma Reconstruction

2011;4:69–72
 PATIENT EVALUATION AND
ANTIBIOTIC TIMING
• Definitive repair of a mandibular fracture is by no
means a surgical emergency.
• Treatment may often be delayed in the multiply
injured patient
• Every attempt should be made to manage these
patients expeditiously in an effort to minimize
associated patient discomfort and fibrinous
deposition within the fracture segment
• Prophylactic antibiotics should be administered
to every patient who sustains compound
mandibular fractures
 TREATMENT METHODS
• Protocols for angle fractures involve rigid fixation in conjunction
with intraoperative maxillomandibular fixation (MMF)

• This produces absolute stability leading to primary bone union and

permits immediate limited postoperative physiological function

• Current literature supports management of noncomminuted

isolated fractures of the mandibular angle with a single 2.0-mm
miniplate secured to the superior surface of the mandible, via a
transoral approach, which provides functionally stable fixation with
the lowest reported complication rate.

• In the case of comminuted angle fractures or in the event that

reduction is not possible through an intraoral approach, an
extraoral technique with placement of a 2.4-mm reconstruction
plate is the recommended treatment
 CONCLUSION
• Mandibular angle fractures continue to present
challenges to reconstructive surgeons
• The use of a single miniplate on the superior
border of the mandible for noncomminuted angle
fractures and an extraoral approach with larger
reconstruction plates for comminuted fractures
are the current preferred methods of treatment
• The ultimate goal is safe and successful
establishment of the patient’s preinjury occlusion
and function
 Transoral Miniplate Fixation of Mandibular
Angle Fracture with and without 2 Weeks of
Maxillomandibular Fixation: A Clinical Trial
Study

Kazem S. Khiabani, DMD, OMFS

Meghdad Khanian Mehmandoost

Oral and Maxillofacial Surgery, Ahwaz Jundishapur University of

Medical Sciences, Ahwaz, Iran

Craniomaxillofac Trauma Reconstruction 2013;6:107–114

Aim : to compare efficiency and complications of using one
miniplate with and without MMF in mandibular angle
fractures
Methods and Materials :Forty patients with facial trauma with
mandibular angle fractures including displaced and
unfavorable fractures were categorized into two groups of 20
persons.
In all patients, one miniplate was placed on the external
oblique ridge.
In the first group, patients had light maxillomandibular elastic
bands just after surgery but no rigid MMF.
In the second group, patients had rigid MMF for 2 weeks after
surgery
Champy’s ideal line of osteosynthesis (from the AO
Foundation online reference located at
www.aofoundation.org and
www.aosurgery.org)
 DISCUSSION
• All angle fractures treated —both displaced
and nondisplaced, favorable and unfavorable
(except comminuted and long oblique
fractures)—by single miniplate fixation
• Because of many disadvantages, we prefer not
to use rigid MMF. Lack of use of MMF has the
advantages include a quick return to
functionality in patients and higher patient
satisfaction, generally.
 Comparison of three-dimensional plate versus
double miniplate osteosynthesis for treatment
of unfavorable mandibular angle fractures

N.H. Al-Tairi , M.M. Shoushan , M.M. Saad Khedr , S.E.

Abd-alal

Oral and Maxillofacial Surgery Department, Faculty of Dentistry,

Tanta University, Egypt
Oral and Maxillofacial Surgery Department, Faculty of Dentistry,
Thamar University, Yemen

Tanta Dental Journal 12 (2015) 89-98

• Objective: To compare three-dimensional plate versus
double-miniplate osteosynthesis for the stability of
unfavorable mandibular angle fractures
• Patients and methods: Sixteen adult patients with
unfavorable mandibular angle fracture.
Divided into two equal groups –
Group I was treated by 3D miniplate while group II was
treated by two miniplates fixation technique.
Radiographic follow up, adequate reduction, status of teeth
related to the fracture line and hardware condition were
observed. Also, quantitative measurements were performed
to assess bone density at the fracture site and inter-ramus
distance
 DISCUSSION
• Three dimensional (3D) plates have some
hardware related advantages over
conventional miniplates and reconstruction
plates.
• Advantage - easy application and time saving.
simplified adaptation to the bone,
without distortion or displacement of the
fracture, as well as the simultaneous
stabilization at both the superior and inferior
borders
 CRITICAL ANALYSIS
• THE TREATMENT OF ANGLE FRACTURE - by
single miniplate fixation on the superior
border is the better treatment modality
• Maxillo-mandibular fixation should be avoided
post-surgically due to its certain disadvantages
• But again the choice of MMF depends on the
surgeon
THANK YOU