Mandible Angle Fracture 01

Mandible Angle FractureMandible Angle Fracture

가천의과대학교 길병원 구강악안면외과전 창 훈

Mandibular Angle FractureMandibular Angle Fracture

Pape et al (1983), Wald et al (1988) 23~42% of all mandible fracture

Mandible Fracture pattern Direction and amount of force Presence of soft tissue bulk Biomechanical characteristics of the mandible (density and mass) Anatomic structures creating weak area

Mandible angle fracture

Biomechanics of the mandible are associated with high incidence of postsurgical complication

Gerlach (1982), Kai Thu & Terhulzen (1985), Jackson et al (1986), Ikemura et al (1988), Ardary (1989), Iizuka et al (1991)

Iizuka (1991), Ellis (1993), Assael (1994) Mandibular angle fractures are associated with the highest incidence of post

surgical infection of all mandibular fracture

Mandibular angle anatomyMandibular angle anatomy

Mandibular angle is thinner than both body and ramus region Abrupt change in shape from horizontal to vertical rami

Michielet et al (1973) Introduce the concept of miniplate placement along the external obli

que ridge for the treatment of mandibular angle fractures Small, easily bendable noncompression bone plates, attached with

monocortical screws Champy et al (1975, 1976, 1977)

Miniplate system : ideal line of osteosynthesis, location of stable fixation

Raveh et al (1987), Luhr (1986), AO/ASIF advocates (1974) Not feel that the plates offer adequate stabilization of the fracture to

eliminate the need for IMF

Angle Fracture Treatment MethodsAngle Fracture Treatment Methods

Closed reduction Intra-oral OR & non-rigid fixation (wire fixation) Extra-oral OR/IF with an AO/ASIF reconstruction bone plate Intra-oral OR/IF using a solitary Lag screw Intra-oral OR/IF using two 2.0 mm mini-dynamic compression plates Intra-oral OR/IF using two 2.4 mm mandibular dynamic compression plates Intra-oral OR/IF using two non-compression miniplates Intra-oral OR/IF using a single non-compression miniplate Intra-oral OR/IF using a single malleable non-compression miniplate Intra-oral OR/IF using a biodegradable plate

1999 Int.JOMS Ellis 참고인용

Closed reduction Closed reduction oror Intraoral open reduction & non-rigid internal fixationIntraoral open reduction & non-rigid internal fixation

Less fashionable Transosseous wires, circum-mandibular wires, small positional

plates Postsurgical IMF : 6 weeks Complications ; 17%

13 infections, 4 malunion & malocclusion, 3 non-union High incidence of postsurgical complications

Extraoral OR/IF Extraoral OR/IF using the AO/ASIF reconstruction plateusing the AO/ASIF reconstruction plate

AO reconstruction plate is a reinforced plate that is thicker and stronger than the standard AO/ASIF compression plate

3 screws on each side of the fracture provide adequate neutralization of functional forces in the absence of compression (Schmoker et al, 1976)

Comminuted, bone loss or obliquity (can’t use standard compression plates)

7.5% infection, 1 patient required plate remove

Lag screwsLag screws

Niederdellmann et al (1981) Internal fixation using a single lag screw

Rapid and simple method 17 / 88 patient unstable & supplemental fixation method 5 patient (13%) required removal of screws and small sequestra

Intraoral OR/IF using Intraoral OR/IF using two 2.0-mm mini-dynamic compression platestwo 2.0-mm mini-dynamic compression plates

Superior & inferior border of buccal cortex Superior border : small compression plate with monocortical screws Inferior border : large compression plate with biocortical screws

Extraoral approach : Not difficult Intraoral approach : decreased visibility, difficult adaptation 29% (9/30) complications

Intraoral OR/IF usingIntraoral OR/IF usingtwo 2.4mm mandibular dynamic compression platestwo 2.4mm mandibular dynamic compression plates

Because of the high rate of postsurgical complications in patients with two 2.0-mm mini-dynamic compression plate

Standard AO/ASIF technique by application of two compression plates specifically designed for the mandible

2.4mm screws applied monocortically in locations where bicortical engagement would damage normal anatomy

Postsurgical suction drainage was used in all cases 32% infections

Intraoral OR/IF usingIntraoral OR/IF usingtwo noncompression miniplatestwo noncompression miniplates

AO/ASIF recommendation with two compression plate High rates of complication

2.0 mm non-compression mini-plates Superior : monocortical Inferior : bicortical

28% (19/67) complications

Intraoral OR/IF using Intraoral OR/IF using one non-compression miniplateone non-compression miniplate

High rate of complication : two plate Champy et al (1978) : one miniplate

Single 4-hole miniplate and monocortical screws 2~4mm gap at the inferior border

16% complications, but minor and can treated in the outpatient

Intraoral OR/IF usingIntraoral OR/IF usingone malleable non-compression miniplateone malleable non-compression miniplate

Lodde (1995) Reduced the volume of the original champy miniplate by half Not increased in complications

Thin, malleable miniplate (7 hole) & 1.3 mm screws (5mm) 13.7 % complications : 8.7 % further surgical intervention

3/7 Asymptomatic plate fracture, but bony union state 2/7 plate fracture : mobility, 6 weeks IMF

Luhr & Hausmann (1996) 0.9% rate of complication in 352 patients treated by compression pl

ates for angle fracture Ellis & Sinn (1993)

32% rate of complication in 65 patients treated with compression plates for angle fracture

Iizuka & Lindqvist (1993) 6.6% rate of infection and 14% rate of malocclusion for 121 angle fx

Angle fracture complication rate 가 다양한 이유 (Ellis, 1999) Angle fracture 에 국한된 complication 연구가 부족하다 Very different treatment Vary in the etiology of the injury Routine plate remove

Luhr (1982) Large bone plates (usually with compression) fastened with bicortic

al bone screws to provide rigidity

AO/ASIF plateAO/ASIF plate

Plate and screw fixation should provide sufficient rigidity to the fragments to prevent interfragmentary mobility during active use of the mandible

2 Miniplates2 Miniplates

Levy (1991) 2 miniplate : 3.1% complication ( superior buccal cortex, 2nd 6-hole) Single miniplate : 20 % complication 2 miniplate plus postsurgical IMF :

• higher complication (7.1%) than no IMF Vallenntinpo 1994 Choi (1995)

Separation of the fracture line and lateral displacement of the proximal fragment at the lower mandibular margin

2nd plate : inferior border Severely disturbed biological surrounding (need for more rigid fixation)

Old, comminuted, infected or severely dislocated fracture Edentulous mandible or with atypical tension/pressure forces due to poor

dentition or pathological occlusion

1 Miniplate1 Miniplate

Champy et al (1976) One plate at the superior border of the mandible ventral to the exter

nal oblique line Choi et al (1995) Ellis (1999) Shierle et al (1997) Low complication rates with monocortical miniplate fixation

Michelet et al, 1973 Champy et al, 1978 Gerlach et al, 1983

Bio resorbable plateBio resorbable plate

Synthetic bioabsorbable materials : 30 years Cutright and Hunsuck (1972)

Orbital floor fracture : use of resorbable materials Bos (1989)

Attempted by using poly-L-lactide acid monomers : successful rate But, rapid decline in tensile strength : 1 week

Eppley (1996) Polyglycolic acid materials 50% loss of original strength in the 2 week after placement Total loss of the strength and consistency after 6 weeks

Combination of the 2 materials in varying ratio Lorenz Lactosorb system

PLLA and PGA Allow 70% of the initial strength to be retained during the first 6-8 weeks

AO/ASIF principleAO/ASIF principle

1. Anatomic reduction

2. Rigid fixation

3. Atraumatic surgical technique

4. Immediate active function

1994, AO/ASIF Change second principle : “ functionally stable fixation ”

Single miniplate “ neutralize ” functional forces

Bite force & BiomechanismBite force & Biomechanism

3rd molar3rd molar

Mandible Fracture %Mandible Fracture %

하악골 골절 중 차지하는 비율 , 성 , 나이 , 직업 , 외상 방법 ? 위치

수술까지 경과시간 , MMF 기간 , 입원기간 , 합병증 수술 접근 방법 , 마취방법 , 재수술여부 흡수성 , 비흡수성 , 제 3 대구치 잔존 , 발거 , 고정술 방법 환자의 만족도 ( 교합 ), 개구장애 ? 저작력변화

Question Fractuer stability vs Infections

ComplicationsComplications

Champy et al (1978) The combination of the forces of elevator muscles and occlusal forc

es results in a natural band of tension along the superior border in the angle region

Outcomes of Patients With Teeth in the Line of ManOutcomes of Patients With Teeth in the Line of Mandibular Angle Fractures Treated With Stable Internal dibular Angle Fractures Treated With Stable Internal

FixationFixationJOMS 2002 60:863-865JOMS 2002 60:863-865 EllisEllis

결과 골절선에 치아 존재 : 85% (345/402) 수술 동안 치아의 제거 : 75% (258/345) 술후 감염 : 19% (75/402) 평균시간 : 8.1 weeks P/R : 19% (75/402) 치아와 관련없는 우각부 골절 감염율 : 15.8% 치아와 관련된 우각부 골절 감염율 : 19.1%

• 치아를 잔존시킨 경우 : 19.5%• 치아를 제거한 경우 : 19.0%

치아와 관련없는 우각부 골절 P/R : 17.5% 치아와 관련된 우각부 골절 P/R : 18.8%

• 치아를 잔존시킨 경우 : 19.5%• 치아를 제거한 경우 : 18.6%

결론 치아가 골절선에 존재하면 술후 합병증 위험이 증가하지만 ,

유의성은 없다 . 술후 감염은 치아의 발거에 대한 문제와 연관이 없다 .

Outcomes of Patients With Teeth in the Line of ManOutcomes of Patients With Teeth in the Line of Mandibular Angle Fractures Treated With Stable Internal dibular Angle Fractures Treated With Stable Internal

FixationFixationJOMS 2002 60:863-865JOMS 2002 60:863-865 EllisEllis

Angle fracture 에서 술후 complication 이 높은 이유 Method of treatment The time between injury and treatment The oral health of the patient Presence or absence of a tooth in the fracture line

The criteria of tooth extraction (Methods) Fractured teeth Pericoronal / periodontal infection Gross caries Tooth mobility Exposure of the apical half or more of the root (including the apex) Inability to reduce the fracture without tooth removal

Muller (1964) Multirooted teeth (ie, molars) be removed

James et al (1981) 4+ mobility, root fracture, apical pathology, not necessary for stability (39%)

Kahnberg and Ridell (1979) 59% teeth left : clinical and radiographic sucess

Do mandibular Third Molars Alter the Risk of Angle Fracture?Do mandibular Third Molars Alter the Risk of Angle Fracture?Fuselier, Ellis, Dodson Fuselier, Ellis, Dodson JOMS 2002 JOMS 2002 60:514-51860:514-518

Results & Conclusions Study sample : 1,210 patients Patients with M3 : 2.1 times chance of angle fracture Angulation & occlusal position of M3 : mesioangulation

Intact superior border : structural stability of the angle region Does the removal of M3 “strength” the mandible or does it remain

“weak” ? Angle fracture incidence

Vector of force Amout of force Musculatrue of the face Architecture of the mandible M3 presence or absence

Is the mandibular third molar a risk factor for mandiIs the mandibular third molar a risk factor for mandibular angle fracture?bular angle fracture?

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000 89:143-6Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000 89:143-6Ma’aita, AlwrikatMa’aita, Alwrikat

Results M3 를 가진 426 명 중 127 명이 우각부 골절 (29.8%) M3 가 없는 189 명 중 25 명이 우각부 골절 (13.2%)

Conclusions Mandibular angle that contain an impacted M3 is more susceptible to fracture

Angle

fracture Relative

riskPosition Yes No Total

Mesioangular

Vertical

Distoangular

Horizontal

Total

36

59

20

12

127

165

79

30

25

299

201

138

50

37

426

1

2.4

2.2

1.8

Angle

fracture Relative

riskPosition Yes No Total

Erupted M3

Partially erupted M3

Unerupted M3

Total

29

35

63

127

181

100

18

299

210

135

81

426

1

1.9

5.6

M3 position & angle fx risk M3 & angle fx

Is the mandibular third molar a risk factor for mandiIs the mandibular third molar a risk factor for mandibular angle fracture?bular angle fracture?

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000 89:143-6Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000 89:143-6

Mandible The strongest and most rigid component of the skeleton But, more commonly fractured than the other bones of the face

Ellis (1985) Mandibulr angle fracture : 30% of the mandibular fractures

Wolujewicz (1980) No relationship between the state of eruption of M3 and angle fracture

Tevepaugh and Dodson (1995) 3.8 times more fracture with M3

Halazonetis (1968), Amartunga (1988) Twice occur in dentate patients compared with edentate patients

Reitzik (1978) Unerupted M3 angle will fracture with only 60% of the force necessary to

fracture the angle when the M3 is erupted

The Effect of Mandibular Third Molar Presence and The Effect of Mandibular Third Molar Presence and Position on the Risk of an Angle FracturePosition on the Risk of an Angle FractureLee, DodsonLee, Dodson JOMS 2000 58:394-398JOMS 2000 58:394-398

Purpose Assessment of the relationship between M3 and angle fractures

Patients and Methods M3 position : 9 categories (Pell and Gregory classification)

Results Patient with M3 had a 1.9 times greater chance of an angle fx

Conclusions M3 present have an increased risk for angle fractures (1.9 times) M3 position is only one important risk factor

The Effect of Mandibular Third Molar Presence and The Effect of Mandibular Third Molar Presence and Position on the Risk of an Angle FracturePosition on the Risk of an Angle Fracture Lee, DodsonLee, Dodson JOMS 2000 58:394-398JOMS 2000 58:394-398

Mandibular fracture patterns Direction and amount of force Presence of soft tissue bulk Biomechanical characteristics of the mandible (bone density and mass) Anatomic structures creating weak areas

Reitzik et al (1978) Mandible with unerupted M3s required 40% less force to be fractured than

mandible with fully erupted M3 Hypothesis

Presence of M3s decreases bone mass, thereby increasing the risk of fx Deeper impactions increasing the risk of fracture

Huelke et al (1961,1962,1964) Fracture occur more frequently in dentate than in edentulous

Tevepaugh & Dodson (1995) Fail to confirm a relationship between M3 position and fracture

The Effect of Mandibular Third Molar Presence and The Effect of Mandibular Third Molar Presence and Position on the Risk of an Angle FracturePosition on the Risk of an Angle Fracture Lee, DodsonLee, Dodson JOMS 2000 58:394-398JOMS 2000 58:394-398

Deepest impacted M3s 50% decrease in angle fracture risk

Other factors (Nahum 1975) Soft tissue character Remaining dentition state

Weiss (1965) Angle region was more prone to fracture in partially or fully edentulo

us mandibles than in dentulous ones Tams et al (1996)

Biomechanical property of the mandible during angle fractures• Greatest amount of positive bending moment• Small amount of torsion• Greatest amount of shear force

John et al M3 ext or not ? Condyle fx

An investigation into the relationship between mandibular An investigation into the relationship between mandibular third molars and angle fractures in Nigeriansthird molars and angle fractures in Nigerians

Ugboko Ugboko British JOMS 2000 38:427-429British JOMS 2000 38:427-429

Present Absent TotalMn M3Present 65 343 408Absent 11 71 82Total 76 414 490

Angle fracturePresent Absent Total

Mn M3Erupted 52 279 331

unerupted 24 53 77Total 76 332 408

Angle fracture

Results 65/408 with M3 (16%) vs 11/82 without M3 (13%) Unerupted 24/77 (31%) vs erupted 52/331 (16%)

Conclusions M3 does not necessarily predispose to fractures of the mandibular angle But, angle fractures are more likely to occur with unerupted M3 than erupted M3

Marker et al (1994) Closed reduction with retention of M3 within the line of fracture carries less morbid

ity than rigid fixation and immediate jaw mobility

Are Mandibular Third Molars a Risk Factor for Angle Are Mandibular Third Molars a Risk Factor for Angle Fractures? : Fractures? : A Retrospective Cohort StudyA Retrospective Cohort Study

Tevepaugh & Dodson Tevepaugh & Dodson JOMS 1995 53:646-649JOMS 1995 53:646-649

Results 73 patient with M3, 30 angle fracture (41.1%) 28 patient without M3, 3 angle fracture (10.7%)

Conclusions Patient with M3 were 3.8 times more liable to develop angle

fractures than those without M3 The decreased cross-sectional area of bone associated with M3

weakens the angle The position of the M3 does not affect the site People at risk may benefit from pre-emptive removal of the M3

Relationship between fractures of the mandibular aRelationship between fractures of the mandibular angle and the presence and state of eruption of the lngle and the presence and state of eruption of the l

ower third molarower third molarSafdar, BMedSci, Meechan Safdar, BMedSci, Meechan Oral Surg 1995;79:680-684Oral Surg 1995;79:680-684

Results Significantly greater when unerupted M3 were present Bilateral unerupted M3 predisposed to a fracture at the angle signifi

cantly more than unilateral unerupted M3

Peterson (1991)

• Prophylactic extraction of unerupted M3 : sports

Incompletely erupted third molars in the line of manIncompletely erupted third molars in the line of mandibular fractures ; dibular fractures ; A retrospective analysis of 57 casesA retrospective analysis of 57 cases

Marker, Eckerdal et alMarker, Eckerdal et al Oral Surg 1994;78:426-31Oral Surg 1994;78:426-31

Clinician variablility in characterizing mandible fracturesClinician variablility in characterizing mandible fracturesShetty, Atchison, Belin, WangShetty, Atchison, Belin, Wang JOMS 59;254-261, 2001JOMS 59;254-261, 2001

A Biomechanical Evaluation of Mandibular Angle FrA Biomechanical Evaluation of Mandibular Angle Fracture Plating Techniquesacture Plating Techniques

Haug et alHaug et al JOMS 2001 59:1199-1210JOMS 2001 59:1199-1210

Purpose Evaluate the biomechanical behavior of a vast array of fixation philosophies a

nd technique Materials and Methods

150 polyurethane synthetic mandible replicas Five controls and 5 each of 14 different fixation Vertical loading at the incisal edge & contralateral loading in the molar region

• Lag screw technique• Monocortical superior border plating with varying size of plates & screws• Monocortical 2-plate technique with varying forms of fixation• Monocortical tension band systems with associated bicortical stabilization

plates of various types• Various forms of reconstruction plates

Conclusions Incisal edge loading : all systems met or exceeded postoperative function Contralateral molar loading : fail

A Biomechanical Evaluation of Mandibular Angle FrA Biomechanical Evaluation of Mandibular Angle Fracture Plating Techniquesacture Plating Techniques

Haug et alHaug et al JOMS 2001 59:1199-1210JOMS 2001 59:1199-1210

Dramatic differences in outcomes Individual host factors Variations in the biology of fracture healing and/or surgical technique Biomechanical influences of the particular fixation systems

Ellis et al (1994, 1996) Bite forces in the acute post-OP period are much less than later post-OP perio

d or nonoperated population Kroon et al (1991)

Different loaded torsions could displace a reconstructed fracture Shetty et al

Adaptive systems fared less favorably than the compressive systems

Technique for Applying 2 Miniplates for Treatment oTechnique for Applying 2 Miniplates for Treatment of Mandibular Angle Fracturesf Mandibular Angle Fractures

Choi et alChoi et al JOMS 2001 59:353-354JOMS 2001 59:353-354

Champy method (1978) Separation of the fracture line & lateral displacement of the fragment Posterior open bite on the fracture side MMF ; intraoperative and postoperative

2-miniplate fixation Superior border & inferior border of the mandible Using reduction forcep : superior border fixation Mouth prop on the contralateral molars : inferior border fixation with trocar Advantage

• No MMF : no posterior open bite• Excellent adaptation and good stability at the fracture site

Ellis et al (1992) Unacceptably high rate of complications using 2 miniplates

Mandibular fractures in Townsville, Australia: incideMandibular fractures in Townsville, Australia: incidence, aetioology and treatment using the 2.0 AO/ASInce, aetioology and treatment using the 2.0 AO/ASI

F miniplate systemF miniplate systemSchon et alSchon et al British JOMS 2001, 39:145-148British JOMS 2001, 39:145-148

Summary 1995, 114 patient, 154 mandible fracture

124 fracture (81%) : male, 30 fracture (19%) : female Fight (83%), TA(10%), Falls(3%), Falling objects(3%), sport(2%) Mn angle (43%), symphysis (26%), combine fracture (30%) With M3 : 97% 105 patient : 2.0 AO/ASIF titanium miniplates Complication

• Temporary sensory deficit (3%)

• Minor malocclusion (2%)

• Infection or dehiscence(5%) Conclusion : 2.0 AO/ASIF miniplate system is reliable

An effective technique for open reduction of mandibAn effective technique for open reduction of mandibualr angle fractures using new reduction forceps: teualr angle fractures using new reduction forceps: te

chnical innovationschnical innovationsChoi et alChoi et al Int JOMS 2001, 30:555-557Int JOMS 2001, 30:555-557

우각부에 reduction forcep 을 적용하기 힘들기 때문에 술후 complication 높을 수 있다 .

Precompressing fractures 는 골 접촉면적을 증가시켜서 stability와 healing 에 도움이 된다 .

1 hole ; proximal fragment medial to the oblique line 2 hole ; distal fragment below the oblique line

But, oblique surface fractures : not advised Cause fragment overriding

Treatment of Mandibular Angle Fractures with a MalTreatment of Mandibular Angle Fractures with a Malleable Noncompression Miniplateleable Noncompression Miniplate

Potter & EllisPotter & Ellis JOMS 1999 57:288-292JOMS 1999 57:288-292

Purpose Single, thin, malleable miniplate 로 우각부 골절 치료를 평가

Patients and Methods 51 fracture : OR/IF using one noncompression, thin, malleable miniplate

and 1.3mm self-threading screws No postsurgical MMF

Results 7 (15.2%) complication

• 3 asymptomatic bone plate fracture : already heal, no treatment• 2 bone plate fracture : fracture mobility, requir MMF• 3 infection : I & D

Conclusions Small one bone plate for angle fractures provided adequate fixation But, unacceptable rate of plate fracture, the plate cannot be recommend

ed for routine

Treatment of Mandibular Angle Fractures with a MalTreatment of Mandibular Angle Fractures with a Malleable Noncompression Miniplateleable Noncompression Miniplate

Potter & EllisPotter & Ellis JOMS 1999 57:288-292JOMS 1999 57:288-292

Single, 2mm miniplate was much fewer complication than 2 plates Lodde (1995)

Reduced the volume of the original Champy miniplate by half• Not increased in complication

Seven-hole noncompression titanium miniplate Six 5mm long, 1.3mm diameter self-threading screws Unnecessary to bend

Rigid fixation Forming a stronger bone Little or no MMF Earlier physical rehabilitation & function

Fracture healing factors Minimum disruption of the periosteum and improve vascularity Inadequate cooling of bur (bicortical) Direction of the fracture line Posterior molar occlusion

Treatment methods for fractures of the mandibular angleTreatment methods for fractures of the mandibular angleEllisEllis Int JOMS 1999, 28:243-252Int JOMS 1999, 28:243-252

Angle fracture 가 빈번히 발생하는 원인1. The presence of third molars

2. A thinner cross-sectional area than the tooth-bearing region

3. Biomechanically the angle can be considered a “lever” area Treatment methods : 앞 slide 에 정리 함

Most useful : AO/ASIF or single miniplate

Treatment Reference Sample No.Major

complication

Non-rigid fixation

AO reconnstruction (2.7 mm)

Solitary lag screw

2 mini-dynamic compression (2.0 mm)

2 Mn dynamic compression (2.4 mm)

2 non-compression miniplates (2.0 mm)

1 non compression miniplate (2.0 mm)

1 malleable non-compr (1.3 mm)

Passeri et al, 1993

Ellis, 1993

Ellis & Ghali, 1991

Ellis & Karas, 1992

Ellis & Sinn, 1993

Ellis & Walker, 1994

Ellis & Walker, 1996

Potter & Ellis, 1999

99

52

88

30

65

67

81

51

17 %

7.5 %

13 %

13 %

32 %

23 %

2.5 %

0 %

Treatment methods for fractures of the mandibular angleTreatment methods for fractures of the mandibular angleEllisEllis Int JOMS 1999, 28:243-252Int JOMS 1999, 28:243-252

Discussion No recommend an intraoral two-plate technique

• High rate of sequestra formation, infection and need for subsequent surgery

Two point fixation was much higher than one point fixation Single miniplate fixation

• Complication was easily treated in the outpatient clinic under local anesthesia

• Plate remove was simple Shierle et al (1997)

• One- or two- plate : no significant difference in results

Biomechanical evaluation of new fixation devices foBiomechanical evaluation of new fixation devices for mandibular angle fracturesr mandibular angle fractures

Wittenberg et alWittenberg et al Int JOMS 1997, 26:68-73Int JOMS 1997, 26:68-73

Mandible angle fractures : 23~42% of all mandible fractures

One- or two-plate fixation of mandibular angle fractureOne- or two-plate fixation of mandibular angle fractures?s?

Schierle, Schmelzeisen, Rahn, PytlikSchierle, Schmelzeisen, Rahn, Pytlik J.CMS 1997, 25:162-168J.CMS 1997, 25:162-168

Summary No significant difference Two plate fixation may not offer advantages over single plate

fixation in general 2 plates : more rigid fixation

Photoelastic analysis of miniplate osteosynthesis foPhotoelastic analysis of miniplate osteosynthesis for mandibular angle fracturesr mandibular angle fractures

Rudman et al Rudman et al Oral Surg 1997, 84:129-36Oral Surg 1997, 84:129-36

Relative displacement resistance of standard and loRelative displacement resistance of standard and low-profile bone plates in experimental mandibular anw-profile bone plates in experimental mandibular an

gle fracturesgle fracturesNissenbaumNissenbaum Oral Surg 1997, 83:427-32Oral Surg 1997, 83:427-32

우리는 멀 쓰고 있나 ? 몇 mm 두께인가 ?

A comparison of mandibular angle fracture plating tA comparison of mandibular angle fracture plating techniquesechniques

Haug et alHaug et al Oral Surg 1996, 82:257-263Oral Surg 1996, 82:257-263

Under the conditions described in this in vitro investigation, plate thickeness or pattern made no difference

All failures in this experiment occurred with monocortical screws in the superior border tension band system

Treatment of Mandibular Angle Fractures Using One Treatment of Mandibular Angle Fractures Using One Noncompression MiniplateNoncompression Miniplate

Ellis et alEllis et al JOMS 1996 54:864-871JOMS 1996 54:864-871

Purpose Single miniplate 를 하악 우각부 골절에 사용

Patients and Methods 81 patients: OR/IF using one noncompression miniplate with 2.0m

m self-threading screws, No MMF postsurgically Results

13 patients (16%): complication 2 complication : hospitalization for IV antibiotics and further surgery

• Fibrous union : bone graft Conclusions

Single miniplate is a simple, reliable technique



Champy et al (1978) 3.8% infection : all mandible fracture

Cawood (1985) 50 miniplate fixation Vs 50 wire fixation with 6 weeks MMF

• Malocclusion (8% vs 4%)• Infection (6% vs 4%)• Dehiscence (12% vs 6%)• 42 mm (4 weeks) vs 34 mm (15 weeks)

27 miniplate fixation on angle fracture• Dehiscence (11%)• Malocclusion (3.7%)• Infection (3.7%)

Ellis (1993) AO reconstruction bone plate through extraoral approach : 7.5% complication But, increased OP time & facial nerve damage, hypertrophic scar



Single miniplate : fewest major complication Gap along the inferior border in the immediate postoperative 6 week radiograph ; gap completely closed in all cases

Karasz et al (1986), Champy (1976) Single miniplate offers more resistance to vertical bending force

Kroon et al (1991), Shetty et al (1995) Neither bending nor torsional forces were susfficiently controlled by single m

iniplate fixation Choi et al (1995)

2 miniplates provide much greater stability than a single miniplate Levy et al (1991)

1 or 2 miniplate without MMF : single (20%,2/10) double (0%) complication 2 miniplate plus MMF (14 patient) : 7.1%

Ellis (1994) : 2 miniplate : 29% Haug (1993) : 4 mm screws were as effective as longer lengths



MMF Immobilization of the mandible until the soft tissue incision has healed Postsurgical “settle” the occlusal relationship

Surgery time Champy (1978) : using no preoperative antibiotics, within 12 hours Cawood (1985) : within 24 hours Ellis, Smith, Barnard, Hook, Tuovinen : no difference in complication rate

Infected fractures Champy (1978) : no miniplate use Becker (1979), Tu and Tenhulzen (1985), Johansson (1988), Koury and El

lis (1992), Koury (1994) : successful treatment Johansson et al (1988) : 42 infected mandible fracture with miniplate

• Good healing : 28 patient (76%)• Preoperative infection persist : 9 patient (24%)• P/R and MMF for 6-8 weeks : 3 patient• Uncomplicated healing & bone graft : 2 patient

Lag-screw fixation of mandibular parasymphyseal aLag-screw fixation of mandibular parasymphyseal and angle fracturesnd angle fractures

Kallela, Ilzuka et alKallela, Ilzuka et al Oral Surg 1996, 81:510-516Oral Surg 1996, 81:510-516

Advantages Less implant material should be needed Cost should be lower Technique should be simple (no need to bend plates) Surgical exposure should be limited

Complications 9%, 14% Niederdellman and Shetty (1987) : 4% complication Ellis and Ghali (1991) : 13% Assaell (1993) : high incidence of technique-related failures

Stability testing of a two miniplate fixation techniquStability testing of a two miniplate fixation technique for mandibular angle fractures.e for mandibular angle fractures.

An in vitro studyAn in vitro studyChoi et al J. Cranio Maxillofac Surg 1995 23:122-125Choi et al J. Cranio Maxillofac Surg 1995 23:122-125

Champy et al (1975) Miniplate and monocortical screws fixation Minimal facial scar, easy adaptation, short operation time, facial & inferi

or alveolar nerve damage decrease Raveh and colleagues (1987) and AO/ASIF advocates (1983)

Do not offers susfficient stabilization without IMF Kroon (1991)

Loading force close to the fracture line : gaping at lower border Frost et al (1991), Ellis and Karas (1992)

Two miniplate fixation : external oblique line + inferior border Two miniplate technique provided a significantly higher resistance to

the loading force close to the fracture line Luhr (1972), Niederdellman and Schilli (1973)

Eccentric dynamic compression plate (EDCP) Used without superior border stabilization (but, frequently recommand)

Fracture Line Stability as a Function of the Internal Fracture Line Stability as a Function of the Internal Fixation System : Fixation System :

An In Vitro Comparison Using a Mandibular Angle Fracture ModelAn In Vitro Comparison Using a Mandibular Angle Fracture ModelVivek Shetty et al 1995 JOMS 53:791-801Vivek Shetty et al 1995 JOMS 53:791-801

Compressive systems Eccentric dynamic compression plate Wurzburg plate Luhr plate Solitary lag screw technique

Adaptive fixation systems Champy miniplate Mennen clamp plate

Conclusions Compressive fixation systems are biomechanically superior to adap

tive systems And provide good immediate function stability to reduced mandibula

r angle fractures

Modified Technique for Adapting a Mandibular AnglModified Technique for Adapting a Mandibular Angle Superior Border Platee Superior Border PlateGerard 1995 JOMS 53:220-221Gerard 1995 JOMS 53:220-221

A Microplate and Screw Technique for Intraoral OpeA Microplate and Screw Technique for Intraoral Open Reduction of Mandibular Angle Fracturesn Reduction of Mandibular Angle Fractures

Haug 1995 JOMS 53:218-219Haug 1995 JOMS 53:218-219

Wire fixation Surgical access limits the placement of holes in the superior border Inferior alveolar nerve paresthesia Lingual nerver damage : dissection Adjacent teeth root damage Difficult to tightening of wire knot Wire knot occasionally eroded through the mucosa Often break just prior to the last twist

Microplate & screw technique Trapezoidal flap Microscrews : 4.0~5.0 mm in length, monocortical 6 weeks MMF

Titanium More cost

Clinical and in vitro evaluation of mandibular angle fClinical and in vitro evaluation of mandibular angle fracture fixation with the two-miniplate systemracture fixation with the two-miniplate system

Choi et alChoi et al Oral Surg 1995, 79:692-5Oral Surg 1995, 79:692-5

Treatment of Mandibular Angle Fracture:Treatment of Mandibular Angle Fracture:Plate and Screw FixationPlate and Screw Fixation

Assael 1994 JOMS 52:757-761Assael 1994 JOMS 52:757-761

Treatment of Mandibular Angle Fractures Using TwTreatment of Mandibular Angle Fractures Using Two Noncompression Miniplateso Noncompression Miniplates

Ellis 1994 JOMS 52:1032-1036Ellis 1994 JOMS 52:1032-1036

Materials and Methods 4-hole noncompression miniplates with 2.0mm screws Superior plate : monocortical Inferior plate : bicortical No MMF

Results 19 / 67 patient : 28% complication Postoperative infection requiring surgical drainage ( n = 17 ) < 6 weeks : 47% 6-10 weeks : 24% > 10 weeks : 29%

Conclusions 2 noncompression miniplate was easy, but resulted in an unacceptable rat

e of infection



Passeri and Ellis (1993) Traditional treatment method : 17% complication

Ellis (1993) AO reconstruction bone plate through an extraoral approach : 7.5%

complication AO/ASIF (1989)

Two compression bone plate recommend Ellis (1992)

Two minidynamic compression plates with 2.0mm screws : 29% complication

Ellis (1993) Stronger dynamic compression plates using 2.4mm screws : 32% c

omplication



Infection factors Intraoral approach : higher bacterial exposure Traumatic disruption Surgical disruption Teeth in the fracture line : removal vs leaving Compression or noncompression Patient status : nutrition, compliance, oral hygiene, substance abuse

• IV drug user : 30 % complication

• Chronic non-IV drug user and alcoholics : 19 and 15.5%

• No abuse substance : 6 %

Treatment of Mandibular Angle Fractures:Treatment of Mandibular Angle Fractures:Transoral Internal Wire FixationTransoral Internal Wire Fixation

Marciani, Anderson, Gonty 1994 JOMS 52:752-756Marciani, Anderson, Gonty 1994 JOMS 52:752-756

Kazanjian (1933) : preantibiotic era Transoral open reduction

Antibiotic : extraoral open reductionn Shira (1954)

Intraoral approach for mandibular angle fracture involving a tooth in the line of fracture

Hooley (1969) Intraoral inferior border wiring ; postoperative mental nerve anesthesia

Sazima et al (1971) “Transoral open reduction” using transosseous wiring

Champy et al (1978) Miniature screw and plate, monocortical

Complication rate 17%

Bite Forces in Patients Treated for Mandibular AnglBite Forces in Patients Treated for Mandibular Angle Fractures: e Fractures: Implications for Fixation RecommendationsImplications for Fixation Recommendations

Tate, Ellis 1994 JOMS 52:734-736Tate, Ellis 1994 JOMS 52:734-736

Methods Healthy adult male : 50 kilopounds OR/IF using 2 miniplates inserted by a transoral approach No MMF

Results Incisor bite force : no significant difference Molar bite forces

• statistically significant reduction in bite force (6 week) Possible reasons

Protective neuromuscular mechanisms Traumatic and surgical damage to the masseter and temporalis muscles Transfacial trochar : masseter muscle damage

Conclusions Amount of fixation required for given fracture may be reduced

Rigid internal fixation of fractures in the angular regRigid internal fixation of fractures in the angular region of the mandible: ion of the mandible:

An analysis of factors contributing to different complicationsAn analysis of factors contributing to different complicationsIizuka, Lindqvist PRS 1993, 91:265

Treatment of mandibular angle fractures using the Treatment of mandibular angle fractures using the AO reconstruction plateAO reconstruction plate

Ellis JOMS 1993, 51:250-254

Complications of nonrigid fixation of mandibular anComplications of nonrigid fixation of mandibular angle fracturesgle fractures

Passeri, Ellis, Sinn JOMS 1993, 51:382-384

Treatment of mandibular angle fractures using two Treatment of mandibular angle fractures using two 2.4-mm dynamic compression plates2.4-mm dynamic compression plates

Ellis JOMS 1993, 51:969-973

Treatment of mandibular angle fractures using two Treatment of mandibular angle fractures using two mini dynamic compression platesmini dynamic compression plates

Ellis JOMS 1992, 50:958-963

Biomechanical validation of the solitary lag screw teBiomechanical validation of the solitary lag screw technique for reducing madibular angle fractureschnique for reducing madibular angle fractures

Shetty & Caputo JOMS 1992, 50:603-607

Single oblique lag screw fixation of mandibular anglSingle oblique lag screw fixation of mandibular angle fracturese fractures

Farris, Dierks laryngoscope 1992, 102:1070-1072

Screw-wire osteosynthesis technique for intraoral oScrew-wire osteosynthesis technique for intraoral open reduction of mandibular angle fracturespen reduction of mandibular angle fractures

Dym, Coro, Ogle JOMS 1992, 50:1247-1248

Lag screw fixation of mandibular angle fracturesLag screw fixation of mandibular angle fracturesEllis JOMS 1991, 49:234-243

A Computer Study of Biodegradable Plates for InterA Computer Study of Biodegradable Plates for Internal Fixation of Mandibular Angle Fracturesnal Fixation of Mandibular Angle FracturesTams, Loon, Otten, BosTams, Loon, Otten, Bos JOMS 2001 59:404-407JOMS 2001 59:404-407

Purpose Suitability of small biodegradable plate systems

Materials & Methods 2 polylactide(PLA) midiplates 2 PLA maxiplates 1st fixation : external oblique ridge 의 buccal 2nd fixation

• Halfway up the height of the mandible• Lower border

Results PLA maxiplates on halfway up the height : bite force tolerable But, yield strain of PLA was not exceeded in any strategies

Conclusions 2 PLA maxiplates External oblique ridge & halfway up the height of the mandible

A Computer Study of Biodegradable Plates for InterA Computer Study of Biodegradable Plates for Internal Fixation of Mandibular Angle Fracturesnal Fixation of Mandibular Angle FracturesTams et al.Tams et al. JOMS 2001 59:404-407JOMS 2001 59:404-407

Large PLA plates & screws (Rozema 1992, Bergsma 1995) Unacceptable long degradation period Risk of late degradation complications

The dimensions of the PLA plate

1 PLA midi- or maxiplate fixation on angle : fracture mobility (+) Angle fracture (Tams 1996, 1997)

Bite forces : high bending moments, low torsion moments, high shear forces Negative bending moments Positive bending moments≪

Length Width Thickness

PLA midiplate 22.0 5.0 2.5

PLA maxiplate 26.0 7.0 2.0

The Efficacy of Bioresorbable Fixation in the Repair The Efficacy of Bioresorbable Fixation in the Repair of Mandibular Fractures: An Animal Studyof Mandibular Fractures: An Animal Study

Quereshy et alQuereshy et al JOMS 2000 58:1263-1269JOMS 2000 58:1263-1269

Purpose Analyze and compare bioresorbable fixation with titanium system

Materials and Methods Iatrogenic left mandibular angle fracture & OR/IF

• Bioresorbable fixation

• Titanium fixation Allow function immediately

Conclusions Bioresorbable fixation system is effective in the treatment of mandib

ular angle fractures in a dog model

The Efficacy of Bioresorbable Fixation in the Repair The Efficacy of Bioresorbable Fixation in the Repair of Mandibular Fractures: An Animal Studyof Mandibular Fractures: An Animal Study

Quereshy et alQuereshy et al JOMS 2000 58:1263-1269JOMS 2000 58:1263-1269

Bone plates Biocompatible and strength Several potential postoperative problems

• Visibility or palpability

• Hardware loosening with resulting extrusion

• Temperature sensitivity to cold

• Screw migration and maxillary sinusitis

• Bone atropy or osteopenia caused by stress shielding & corrosion

• Interference with radiographic imaging and radiation therapy

• Allergic reactions

• Intracranial migration in cranio-orbital surgery

• Possibility of causing growth restriction of the craniofacial skeleton in pediatric patients

A computer study of fracture mobility and strain on A computer study of fracture mobility and strain on biodegradable plates used for fixation of mandibulabiodegradable plates used for fixation of mandibula

r fracturesr fracturesTams et alTams et al JOMS 1999, 57:973-981JOMS 1999, 57:973-981

CASE REPORTCASE REPORT

1997~2002

1997 ~ 2002 110 Patient 21 명이 추적관찰기간이 4 주 미만 1 명이 전신질환으로 closed reduction 평균연령 ; 26.7 세 ( 남자 85 명 , 여자 25 명 좌측 69 명 , 우측 41 명 Isolated fx 56 명 , combine fx 54 명 (condyle head 1 명 ) Without M3 6 명 , with M3 104 명 비발치 85 명 , 발치 19 명 수상후 수술까지 평균 6 일 소요 (1 일 ~19 일 ) 입원후 수술까지 평균 4 일 소요 (1 일 ~19 일 ) 수술후 퇴원까지 평균 7.26 일 소요 (2 일 ~18 일 ) 4 주이상 추적관찰환자의 평균 기간은 7 개월 (1 개월 ~45 개월 ) 1 달 이상 추적 관찰 환자 88 명중 54 명 고정판제거 5.7 개월 소요

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Mandible Angle Fracture 01