Tecnica de Champy

YIJOM-2725; No of Pages 7

Clinical Paper

Trauma

Int. J. Oral Maxillofac. Surg. 2013; xxx: xxx–xxxhttp://dx.doi.org/10.1016/j.ijom.2013.07.001, available online at http://www.sciencedirect.com

A comparative analysis of theefficacy of cortical screws as lagscrews and miniplates forinternal fixation of mandibularsymphyseal region fractures: arandomized prospective studyA. Agnihotri, S. Prabhu, S. Thomas: A comparative analysis of the efficacy of corticalscrews as lag screws and miniplates for internal fixation of mandibular symphysealregion fractures: a randomized prospective study. Int. J. Oral Maxillofac. Surg. 2013;xxx: xxx–xxx. # 2013 International Association of Oral and Maxillofacial Surgeons.Published by Elsevier Ltd. All rights reserved.

Abstract. The management of facial trauma is one of the most rewarding anddemanding aspects of oral and maxillofacial surgery. Being the most prominentmobile bone of the facial skeleton, mandible fracture occurs more frequently thanany other fracture. In this study, open reduction and internal fixation was performedfor isolated mandibular symphyseal region fractures using cortical screws (as lagscrews) in 40 patients and using miniplates in 40 patients. Clinical and radiologicalevaluations were made at 6 months postoperatively. Primary stability of fracturesegments, postoperative swelling, restricted lip mobility, infection, wounddehiscence, implant removal, and mal-union or non-union of fracture segments wasevaluated. Primary stability was achieved in 100% of cases treated with corticalscrews, whereas for patients treated with miniplates, 97.5% attained primarystability, while one case (2.5%) showed persistent clinical mobility. Postoperativecomplications were noted in 13 (16.25%) of the total 80 patients. The duration ofpostoperative swelling was less in patients treated with cortical screws compared topatients treated with miniplates. It is concluded that cortical screw fixation is aneffective procedure for the treatment of symphyseal region fractures, but theprocedure is somewhat technically sensitive.

Please cite this article in press as: Agnihotri A, et al. A comparative analysis of the effic

miniplates for internal fixation of. . ., Int J Oral Maxillofac Surg (2013), http://dx.doi.org

0901-5027/000001+07 $36.00/0 # 2013 International Association of Oral and Maxillofacial Surge

A. Agnihotri, S. Prabhu, S. ThomasDepartment of Oral and Maxillofacial Surgery,People’s College of Dental Sciences andResearch Centre, Bhanpur, Bhopal, MadhyaPradesh, India

Key words: lag screws; miniplates; symphysealregion fractures.

Accepted for publication 1 July 2013

Traumatic injuries to the maxillofacialskeleton occur due to a variety of causes,such as road traffic accidents, sportsinjuries, interpersonal violence, gunshot

injuries, etc. For the surgeon who operateson patients presenting with facial trauma,fractures of the symphyseal region ofthe mandible are a common entity. The

mandible is the second most commonlyfractured bone of the maxillofacial skeletonbecause of its position and prominence.Although there is wide variance in the

acy of cortical screws as lag screws and

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ons. Published by Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ijom.2013.07.001



2 Agnihotri et al.


Fig. 1. Group A: (a) Intraoperative miniplate fixation; (b) postoperative orthopantomograph at6-month follow-up.

reported percentage of fracture of the ante-rior mandible, aggregate analysis placesthis at approximately 17% of all mandibu-lar fractures.1,2

Internal fixation of mandibular fractureswith miniplates (in conformity with thetension band principle) was first intro-duced by Michelet in 1973 and was latermodified by Champy et al.3

The lag screw technique in maxillofa-cial surgery was first advocated by Bronsand Boering4 in 1970 and was later rein-troduced by Niederdellmann et al.,5 whostated that at least two screws werenecessary to prevent rotational move-ment of the fragments in oblique frac-tures of the mandible. In North America,its use for the management of anteriormandible fractures became popularthrough the work of Ellis and Ghali.6

However, this modality has not gainedpopularity in India for unexplainedreasons, resulting in the non-availabilityof essential hardware for lag screwfixation.

The purpose of this study was to com-pare the outcomes of treatment usingeither cortical screws (used as lag screws)or miniplates, in patients who had sus-tained a fracture in the mandibular sym-physeal region. The objectives includedcomparative assessments of their ability toprovide adequate primary stability, theneed for any supplemental maxilloman-dibular fixation (MMF), the time requiredto complete the procedures, occlusalderangement, and the incidence of post-operative complications such as wounddehiscence, wound discharge, infection,postsurgical swelling, and any functionallimitation in lower lip function as evi-denced by speech articulation.

Patients and methods

This study was conducted on 80 patientswith clinical and radiological evidence offracture of the symphyseal region of themandible. Patients were assigned to one oftwo groups: group A (n = 40) were treatedby open reduction and internal fixationusing 2.0-mm miniplates, and group B(n = 40) were treated by open reductionand internal fixation using 2.5-mm corticalscrews applied using the lag screw prin-ciple.

Cases with discrete, isolated symphy-seal/parasymphyseal fractures requiringprimary definitive treatment, without anyevidence of infection, were included in thestudy. Cases with uncontrolled systemicdisease, multiple mandibular fractures,mal-union/non-union of fracture seg-ments, and those requiring revision of

Please cite this article in press as: Agnihotr

miniplates for internal fixation of. . ., Int J

previous improper treatment and commin-uted fractures were excluded.

Surgical procedure

Local anaesthesia (lidocaine 2% with1:200,000 epinephrine) was preferredwhenever feasible. Patients with poor ver-bal communication, extreme anxiety, orwho were otherwise uncooperative in nat-ure were elected to be treated under gen-eral anaesthesia. Access to the fracture sitewas generally sought through an intraoralapproach except where a coexistinglaceration was present over the chinregion. The oral cavity was prepared bythorough irrigation with antiseptic povi-done–iodine 1% solution.

Exposure of the fracture site wasobtained by a standard layered dissectionthrough mucosa, mentalis muscle, and theperiosteum. After debridement of the frac-ture line, MMF was applied using archbars ligated to the dental arches. Frag-ments were reduced and held in appositionwith a reduction forceps (bone clamp) andconfirmed visually by verifying the align-ment of the buccal cortex and inferiorborder.

i A, et al. A comparative analysis of the effic

Oral Maxillofac Surg (2013), http://dx.doi.org

For group A patients, 2.0-mm mini-plates were contoured, applied, and fixedusing monocortical screws, in accordancewith Champy’s principles, along the lineof osteosynthesis. A minimum of twoscrews were placed on either side of thefracture line for each of the bone platesapplied (Fig. 1a). For group B patients,two 2.5-mm diameter cortical screws wereplaced using the lag screw principle, withcare taken to ensure co-axial preparationof the gliding and pilot holes, adequateenlargement of the gliding hole using 3-mm diameter drills to prevent threadengagement proximally, and preparationof the countersink (Fig. 2a). Upon com-pletion of the procedure, MMF wasreleased and occlusion verified. The inci-sion was then closed in layers and a pres-sure dressing was applied to the chin. Allpatients received antibiotics and analge-sics postoperatively for a period of 5 days.

Follow-up

The patients were followed up clinicallyafter 24 h, on days 3 and 7 postoperatively,and then at weekly intervals for 6 weeksand at monthly intervals for 6 months.


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Comparison of cortical screws and miniplates 3


Fig. 2. Group B: (a) Intraoperative cortical screw placement; (b) postoperative orthopantomo-graph at 6-month follow-up.

They were followed up radiographicallywith intraoral peri-apical (IOPA) radio-graphs, mandibular anterior occlusalradiographs, and orthopantomographs inthe immediate postoperative period andafter 1 month, 3 months, and 6 months(Figs. 1b and 2b).

Assessment of parameters

Essential demographic data and the timebetween injury and execution of openreduction and internal fixation wererecorded for all of the patients.

The time required for completion of theprocedure, from the incision to the end ofclosure, was monitored by an independentobserver for each patient. Postoperatively,a blinded observer evaluated the patientsfor stability of fixation by manuallymanipulating the mandible and checkingfor inter-fragment mobility at the fracturesite; any movement was considered indi-cative of inadequate stability of internalfixation. These cases were considered forsupplemental MMF.


miniplates for internal fixation of. . ., Int J O

Other parameters assessed were occlu-sion, wound dehiscence, wound discharge,swelling, duration and presence of func-tional restriction of lip movements, mal-union, fibrous union, or non-union, andinfection. An attempt was made to deter-mine statistically if any correlation existedbetween complications such as infectionand the time delay between injury anddefinitive treatment.

Postoperative oedema was evaluated bymeasuring the distance from the mucocu-taneous junction on the lower lip to theupper border of the thyroid cartilage in thevertical axis and the distance between thetwo gonial angles across the chin in thetransverse axis using a 2-0 silk thread,transferring the measurements to a ruler.The average of these two postoperativemeasurements on postoperative day 3was subtracted from the average preopera-tive values to determine the magnitude ofswelling. Duration was determined as thetime required for a return to the averagepreoperative measurements, as determinedon the designated days of follow-up.


ral Maxillofac Surg (2013), http://dx.doi.org

Functional restriction of lip movementwas assessed by asking the patient topronounce words with significant bilabialconsonants, such as ‘bubble’, ‘mumble’,etc.; difficulty in articulation was scored aspresent or absent by all three authors. Inthe case of conflict, the majority scoredetermined the decision.

Observations were recorded on a stan-dardized proforma. Results were evalu-ated by statistical analysis to meet theaforementioned objectives of the study.Data were analyzed by analysis of var-iance (ANOVA), paired t-test, and x2 testof significance between two proportions,with statistical significance set atP < 0.05.

Results

The mean age of patients in this study was33.7 years (range 18–70 years), and themale to female ratio was 10:1. The meantime interval between injury and treatmentfor group A was 9.4 days (range 4–18days) and for group B was 9.5 days (range1–25 days). For the majority of patients ingroup A, the time needed to complete theprocedure ranged between 90 and120 min, while for most in group B thetime required ranged from 120 to 180 min.The difference in time required for com-pletion of the procedures between the twogroups was found to be statistically sig-nificant (Table 1).

In group A, the duration of postopera-tive swelling varied from a minimum of 7days in 24 patients (60%) to a maximum of30 days in four patients (10%), with amean duration of 11.2 days. In group B,swelling was present for a minimum of 4days in 10 patients (25%) to a maximum of14 days in five patients (12.5%), with amean duration of 7.1 days (Table 2). Thedifference in duration of postoperativeswelling between the two groups was sta-tistically significant.

The mean magnitude of swelling ingroup B was 4.49 mm (range 4–5 mm),whereas in group A the mean was4.36 mm (range 3–5.9 mm). The differ-ence in magnitude of swelling as assessedby paired t-test was not statistically sig-nificant (Tables 3 and 4).

Postoperatively, all 80 patients showedrestricted lip mobility that affected articu-lation of speech. In group A, restricted lipmobility was present for a minimum of 4days in 24 patients (60%) and to a max-imum of 10 days in four patients (10%),with a mean of 5.8 days. In group B,restricted lip mobility was present for aminimum of 4 days in 35 patients (87.5%)and five patients showed restrictions for 10


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4 Agnihotri et al.


Table 1. Comparison of time required for procedures.

Time required forcompletion ofprocedure (min)

Group A (n = 40)* Group B (n = 40)yx2 value P-value

Procedure underlocal anaesthesia

Procedure undergeneral anaesthesia

Procedure underlocal anaesthesia

Procedure undergeneral anaesthesia

�30 and <60 0 (0%) 0 (0%) 5 (12.5%) 0 (0%) 220.30 <0.0001,significant�60 and <90 8 (20%) 0 (0%) 5 (12.5%) 0 (0%)

�90 and <120 4 (10%) 20 (50%) 0 (0%) 0 (0%)�120 and <150 0 (0%) 0 (0%) 15 (37.5%) 0 (0%)�150 and <180 4 (10.0%) 0 (0%) 15 (37.5%) 0 (0%)�180 and <210 0 (0%) 4 (10%) 0 (0%) 0 (0%)

* Group A were treated by open reduction and internal fixation using 2.0-mm miniplates.yGroup B were treated by open reduction and internal fixation using 2.5-mm cortical screws applied using the lag screw principle.

Table 2. Comparison of the duration of postoperative swelling.

Swelling Group A (n = 40)* Group B (n = 40)y x2 value P-value

Present for 4 days 0 (0%) 10 (25%) 42.79 <0.0001,significantPresent for 7 days 24 (60%) 25 (62.5%)

Present for 14 days 12 (30%) 5 (12.5%)Present for 1 month 4 (10%) 0 (0%)Total 40 (100%) 40 (100%)

* Group A were treated by open reduction and internal fixation using 2.0-mm miniplates.yGroup B were treated by open reduction and internal fixation using 2.5-mm cortical screws applied using the lag screw principle.

Table 3. Swelling in group A and group B: descriptive statistics.

Mean n SD SEM

Group A* Pre-treatment 38.80 40 2.92 0.46Post-treatment 43.16 40 3.09 0.48

Group By Pre-treatment 32.58 40 1.11 0.17Post-treatment 37.08 40 1.10 0.17

SD, standard deviation; SEM, standard error of the mean.* Group A were treated by open reduction and internal fixation using 2.0-mm miniplates.yGroup B were treated by open reduction and internal fixation using 2.5-mm cortical screws

applied using the lag screw principle.

days, with a mean of 4.5 days. The dif-ference between the groups with regard torestriction of lip mobility was statisticallysignificant (Table 5).

Clinically stable fixation (as determinedby manual testing for inter-fragmentarymobility) was obtained for all patients ingroup B and all but two patients in group Awhen examined on the first postoperativeday. Supplemental immobilization withMMF for 6 weeks was advised for thetwo patients in group A with unstableinternal fixation. However, satisfactory



Table 4. Comparison of swelling in group A an

Paired differences

Mean SD

Group A* �4.36 0.70

Group By �4.49 0.35

SD, standard deviation; SEM, standard error of* Group A were treated by open reduction anyGroup B were treated by open reduction anzSignificant (P < 0.05).

radiographic alignment of the fracturedsegments and satisfactory occlusion wasobtained in all patients at the conclusion oftreatment and remained so throughout theobservation and follow-up period (Figs. 1band 2b).

Postoperative complications were notedin 13 out of the total 80 patients (16.25%).Complications were divided into two cate-gories: major and minor. Major complica-tions included infection with or withoutimplant loosening, whereas minor compli-cations included wound dehiscence with



d group B by Student’s paired t-test.

SEM 95% CI of the difference

0.11 �4.58 to �4.13

0.05 �4.61 to �4.38

the mean; CI, confidence interval.d internal fixation using 2.0-mm miniplates.d internal fixation using 2.5-mm cortical screws

or without discharge. Patients with majorcomplications underwent implant removaland antibiotic therapy, whereas those withminor complications were placed on localirrigation with or without antibiotics.

Eight patients in group A (20%) suf-fered complications. Four (10%) patientshad major complications, which initiallyresponded to antibiotics, but recurrentsinus formation and discharge promptedremoval of plates and screws after 2months. As there was clinical bony union,no further fixation was required. A minorcomplication in the form of soft tissueinfection was encountered at 1 monthpost-treatment in four (10%) additionalpatients in group A, which resolved withantibiotics (Fig. 3).

Only minor complications wereobserved in group B, occurring in fivepatients (12.5%). One (2.5%) patienthad soft tissue swelling, which resolvedfollowing extraction of the tooth in thefracture line and the use of antibiotictherapy; four patients (10%) had wounddehiscence, which was managed with


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t df P-value

39.20 39 0.000z

80.83 39 0.000z





Fig. 3. Comparison of postoperative complications.

Table 5. Comparison of postoperative restriction of lip movement.

Restricted lip mobility Group A (n = 40)* Group B (n = 40)y x2 value P-value

For 4 days 24 (60%) 35 (87.5%) 28.82 <0.0001,significantFor 8 days 12 (30%) 0 (0%)

For 10 days 4 (10%) 5 (12.5%)Total 40 (100%) 40 (100%)

* Group A were treated by open reduction and internal fixation using 2.0-mm miniplates.yGroup B were treated by open reduction and internal fixation using 2.5-mm cortical screws


external support using an adhesive elasticbandage on the chin. These situationsresolved uneventfully (Fig. 3).

When complications were correlatedwith the time interval between injuryand treatment, it was observed that mostof the complications occurred in patientswho had received treatment at 3–7 daysafter injury in both groups, and no com-plications were noted when the patientsreceived treatment within 72 h of injury(Table 6).

Discussion

This study evaluated the efficacy of mini-plates and cortical screws (using thelag screw principle) in open reductionand internal fixation of mandibular sym-physis/parasymphysis region fractures.



Table 6. Correlation of complications and time

Time interval betweeninjury and treatment

G

Wounddehiscence

withoutdischarge

�1 day None

�1 day to <3 days None

�3 days to <7 days None




* Group A were treated by open reduction anyGroup B were treated by open reduction an

Notable results found in the comparisonof the two techniques are outlined below.

A shorter duration of postoperativeoedema and functional lip restrictionwas found with the use of lag screws ascompared to miniplates, in spite of similarsurgical access. It may be presumed thatthe greater quantity of implanted hardwareand the greater amount of bone drillingrequired for placement of a large numberof screws in the miniplate group contrib-uted to more persistent postsurgicaloedema and associated functional liprestriction. A minimally invasive techni-que for the treatment of anterior mandib-ular fractures has been proposed byForrest,7 but this has limitations such asdifficulty in the direct visualization of thefracture site, assessment of the anatomicalreduction, inability to control reduced seg-



interval between injury and treatment.

roup A (n = 40)*

Wounddehiscence

withdischarge

Swelling/discharge

without wounddehiscence

Woudehisc

withdischa

None None NoNone None NoNone 4 4

None 4 NoNone None NoNone None No

d internal fixation using 2.0-mm miniplates.d internal fixation using 2.5-mm cortical screws

ments during lag screw fixation, and hin-drances in the implant placement, etc.

The time duration for completion of theprocedure was less for miniplate fixationas compared to the cortical (lag) screwfixation. This is in contrast with the obser-vations of Ellis and Ghali,6 who reportedthat lag screws could be applied morerapidly as compared to miniplates as thelatter require contouring and adaptation,which may be time-consuming consider-ing the complexities of the anterior mand-ible contour. The authors of the presentstudy had carried out lag screw placementrather infrequently in practice, and there-fore the time required for placement ofcortical screws during the study was initi-ally longer. Ellis and Ghali6 also statedthat the displacement of bone fragmentswas much more common during place-ment of bone plates, since the adequacyof plate contouring was not completelyknown until the screws were insertedand the plate drawn to the mandible. How-ever, none of the patients in the presentstudy had any unsatisfactory reduction asjudged radiographically or clinically.

Primary stabilization achieved by cor-tical screws was greater than that achievedby miniplate fixation (100% of cases in theformer and 97.5% of cases in the latter).Postoperative MMF was not required inpatients who received cortical (lag) screwfixation, indicating earlier functional reha-bilitation. In cases of lag screw fixation, itappears important to manipulate the jawsegments to check for instability afterreleasing the MMF, as recommended byEllis and Ghali.6 According to Ardary, theultimate stability of screw fixation isdependent on the number of screws used,the method of screw placement, bicorticalplacement of screws, and the holdingpower of the screws.8 In cases of doubtfulstability, removal of the lag screws andfixation of miniplates is recommendedinstead of MMF.4 However, a lack of


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Group B (n = 40)y

ndenceoutrge

Wounddehiscence

withdischarge

Swelling/discharge

without wounddehiscence

ne None Nonene None None

None 1ne None Nonene None Nonene None None



6 Agnihotri et al.


stability was encountered in two patientsin the miniplate group in our study andsupplemental MMF did not adverselyaffect the outcome of treatment.

The incidence of major complications(infection requiring hardware removal)was higher with miniplate fixation. Incontrast, minor complications occurredmore frequently with the use of corticalscrews. Four patients (10%) required plateremoval secondary to infection; this is incontrast to the study of Tuovinen et al.,9

who determined the incidence of infec-tion-related plate removal to be 3.6%.Tuovinen et al.9 also removed plates forother reasons, such as patient discomfortand plate fracture, but we did not have anynecessity for removal on these grounds.None of the patients treated with cortical(lag) screws required removal of implants.

The cortical screw fixation group had alower incidence of postoperative compli-cations compared to the miniplate fixationgroup, even though the percentage(12.5%) was much higher compared tothose of the studies by Ellis and Ghali6

and Kallela et al.10 However, all the post-operative complications in the corticalscrew group were minor and resolvedwithout any aggressive management. Pos-sible reasons for infection in the symphy-seal region could be pre-existingsubclinical infection, loose implant, for-eign body reaction, inappropriate sterili-zation, poor host defence, and poor oralhygiene.

None of the patients had any malocclu-sion and there were no instances of drillbreakage. Tiwana et al.11 encountered drillbreakage in 5.9% of cases. This problemwas not encountered in the present study.The probable reason for this could becorrect recognition of the appropriate dril-ling angle required to engage the oppositefracture cortex. Further, while drilling thetraction hole, all attempts were made toengage the opposing cortex as perpendi-cularly as possible and to avoid forcing thedrill. These precautions are necessary tominimize the possibility of drill breakage.Tuovinen et al.9 reported that malocclu-sion developed in 4.7% patients treatedwith miniplates, whereas, Cawood2

reported malocclusion in 6% of patientstreated with miniplates in symphysisregion fractures; these observations arenot in concurrence with those of the pre-sent study. It might be supposed thatcompression caused by the corticalscrews was too extensive, resulting inbone necrosis and misalignment, leadingto malocclusion.12 However, in this study,we found no abnormalities in clinicalhealing of the fractures and occlusion.



Ideal prerequisites to prevent malocclu-sion are stable intraoperative MMF,proper adaptation of plates, drilling holesperpendicular to the fracture line in thecase of cortical (lag) screws, and verifica-tion of accurate anatomic reduction of thelingual cortical plate.

Although it is recommended that osteo-synthesis with miniplates be performedwithin 12 h,9 the majority of our patientsreceived treatment 3–7 days after injury,primarily owing to delays in hospitaliza-tion. However, we did not observe anydisturbances in healing regardless of thetime lapse between injury and treatment.This observation is in agreement withstudies done by Zachariades et al.13 andTuovinen et al.9 However, in an unpub-lished study of 244 mandibular fracturestreated with rigid internal fixation (bicor-tical bone plates according to Associationfor Osteosynthesis/Association for theStudy of Internal Fixation (AO/ASIF)principles), the authors encountered aninfection rate that varied between 1%for those treated within the first weekand 4% for those treated in 2 weeks ormore.14 In the present study, the overallincidence of postoperative complicationswas 16.25% (miniplate group 20%, cor-tical (lag) screw group 12.5%). Onlyminor complications were observed ingroup B, occurring in five patients(12.5%). One (2.5%) patient had soft tis-sue swelling, which resolved followingextraction of the tooth in the fracture lineand the use of antibiotic therapy; fourpatients (10%) had wound dehiscence(without discharge), which was managedwith external support using an adhesiveelastic bandage on the chin. These situa-tions resolved uneventfully. The majorityof complications occurred in patientstreated between 3 and 7 days after injury.This observation needs further validationsince the higher incidence of infectionduring this period may simply be due tothe fact that most patients were treatedwithin this time period.

On analyzing wound dehiscence, onlyfour patients in the cortical (lag) screwgroup developed this problem. The prob-able contributing factors could be inade-quate muscle approximation duringclosure, pre-existing mucosal tear, poororal hygiene, and delayed treatment.Resolution was obtained by irrigationwith normal saline followed by place-ment of an adhesive elastic bandage overthe chin. Unlike Cawood2 who encoun-tered 12% wound dehiscence with mini-plate fixation, we did not observe thiscomplication in the group treated withminiplates.



Assael15 concluded that lag screw fixa-tion of symphyseal fractures had a parti-cularly high rate of technique-relatedfailures. Improper or inadequate counter-sinking was the chief reason for fracturesof the outer cortex or distraction of thefracture when the screw was tightened.Even though the time required for lagscrew fixation was high in our series,adherence to a sound clinical techniquecould be the reason for not having experi-enced technique-related failures.

In lag screw fixation of anterior man-dibular fractures, Kallela et al.10 reportedparesthesia in the region of the mentalnerve distribution in 68% of cases, whichrecovered within an average of 5.4 weeks.Cawood reported an incidence of 8% formental nerve paresthesia and attributedthis to direct damage to the mental nervecaused whilst inserting the Plate.2 Weemphasize the need for careful intraopera-tive identification and preservation of themental nerve along with gentle retractionto mitigate the possibility of this compli-cation.

Champy et al. reported an incidence of0.5% for delayed union and non-union inpatients treated with small plate osteo-synthesis.3 In contrast we did not experi-ence the above problems in our patients.The single patient in the miniplate groupwho needed supplemental MMF also had aclinically stable union by 6 weeks.

In order to achieve a rapid recovery ofform and function, internal fixation sur-gery should meet four basic conditions: (1)anatomic reduction of the bone fragments;(2) functionally stable fixation of the frag-ments; (3) preservation of the blood sup-ply to the fragments by atraumaticoperating technique; and (4) early, active,pain-free mobilization.

All the above requirements are met byminiplates as well as lag screws. Lagscrews have the added advantage ofachieving inter-fragmentary compressionand stability with a minimum of implantmaterial. Our observations suggest thatcortical screw fixation using the lag screwprinciple offers the advantages of fixationusing minimal hardware, functional stabi-lity, is associated with minimal inflamma-tory complications and functionalrestriction, and has a lower incidence ofinfection when considering the treatmentof linear, non-comminuted symphysealregion fractures. The procedure, however,requires more skill and expertise. Thisrecommendation is not complete in itself,as the study is limited by the number ofpatients evaluated. Our observationstherefore require validation with a largersample size.


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Funding

None.

Competing interests

None declared.

Ethical approval

Approval was given by the Ethics Com-mittee of the People’s College of DentalSciences and Research Centre, Bhopal,Madhya Pradesh, India.

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Address:Amit AgnihotriBehind S.P. BungalowOld Bus StandShahdolMadhya Pradesh 484001IndiaTel: +91 90 39245980E-mails: [email protected],[email protected]


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