Mandible Angle Fracture

1
Mandible Angle Fracture

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• ? ? ?

2
Mandibular Angle Fracture

• Pape et al (1983), Wald et al (1988)
• 2342 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 postsurgical infection
  of all mandibular fracture

3
Mandibular angle anatomy

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

4

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

5
Angle 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 ????

6
Closed reduction or Intraoral 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

7
Extraoral OR/IF using 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 (cant use
  standard compression plates)
• 7.5 infection, 1 patient required plate remove

8
Lag 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

9
Intraoral OR/IF using two 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

10
Intraoral OR/IF usingtwo 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

11
Intraoral OR/IF usingtwo 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

12
Intraoral OR/IF using one non-compression
miniplate

• High rate of complication two plate
• Champy et al (1978) one miniplate
• Single 4-hole miniplate and monocortical screws
• 24mm gap at the inferior border
• 16 complications, but minor and can treated in
  the outpatient

13
Intraoral OR/IF usingone 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

14

• Luhr Hausmann (1996)
• 0.9 rate of complication in 352 patients treated
  by compression plates 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

15

• Angle fracture complication rate? ??? ?? (Ellis,
  1999)
• Angle fracture? ??? complication ??? ????
• Very different treatment
• Vary in the etiology of the injury
• Routine plate remove

16

• Luhr (1982)
• Large bone plates (usually with compression)
  fastened with bicortical bone screws to provide
  rigidity

17
AO/ASIF plate

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

18
2 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

19
1 Miniplate

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

20
Bio 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

21
AO/ASIF principle

• Anatomic reduction
• Rigid fixation
• Atraumatic surgical technique
• Immediate active function
• 1994, AO/ASIF
• Change second principle functionally stable
  fixation
• Single miniplate
• neutralize functional forces

22
Bite force Biomechanism
23
3rd molar
24
Mandible Fracture

• ??? ?? ? ???? ??, ?, ??, ??, ?? ??? ??
• ???? ????, MMF ??, ????, ???
• ?? ?? ??, ????, ?????
• ???, ????, ?3??? ??, ??, ??? ??
• ??? ???(??), ????? ?????
• Question
• Fractuer stability vs Infections

25
Complications

• Champy et al (1978)
• The combination of the forces of elevator muscles
  and occlusal forces results in a natural band of
  tension along the superior border in the angle
  region

26
(No Transcript)
27
Outcomes of Patients With Teeth in the Line of
Mandibular Angle Fractures Treated With Stable
Internal FixationJOMS 2002 60863-865 Ellis

• ??
• ???? ?? ?? 85 (345/402)
• ?? ?? ??? ?? 75 (258/345)
• ?? ?? 19 (75/402) ???? 8.1 weeks
• P/R 19 (75/402)
• ??? ???? ??? ?? ??? 15.8
• ??? ??? ??? ?? ??? 19.1
• ??? ???? ?? 19.5
• ??? ??? ?? 19.0
• ??? ???? ??? ?? P/R 17.5
• ??? ??? ??? ?? P/R 18.8
• ??? ???? ?? 19.5
• ??? ??? ?? 18.6
• ??
• ??? ???? ???? ?? ??? ??? ?????, ???? ??. ?? ???
  ??? ??? ?? ??? ??? ??.

28
Outcomes of Patients With Teeth in the Line of
Mandibular Angle Fractures Treated With Stable
Internal FixationJOMS 2002 60863-865 Ellis

• Angle fracture?? ?? complication? ?? ??
• 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

29
Do mandibular Third Molars Alter the Risk of
Angle Fracture?Fuselier, Ellis, Dodson JOMS
2002 60514-518

• 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

30
Is the mandibular third molar a risk factor for
mandibular angle fracture?Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2000
89143-6Maaita, Alwrikat

• Results
• M3? ?? 426? ? 127?? ??? ?? (29.8)
• M3? ?? 189? ? 25?? ??? ??(13.2)
• Conclusions
• Mandibular angle that contain an impacted M3 is
  more susceptible to fracture

M3 position angle fx risk
M3 angle fx
31
Is the mandibular third molar a risk factor for
mandibular angle fracture?Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2000 89143-6

• 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

32
The Effect of Mandibular Third Molar Presence and
Position on the Risk of an Angle FractureLee,
Dodson JOMS 2000 58394-398

• 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

33
The Effect of Mandibular Third Molar Presence and
Position on the Risk of an Angle Fracture Lee,
Dodson JOMS 2000 58394-398

• 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

34
The Effect of Mandibular Third Molar Presence and
Position on the Risk of an Angle Fracture Lee,
Dodson JOMS 2000 58394-398

• 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 edentulous 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

35
An investigation into the relationship between
mandibular third molars and angle fractures in
NigeriansUgboko British JOMS 2000 38427-429

• 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 morbidity than
  rigid fixation and immediate jaw mobility

36
Are Mandibular Third Molars a Risk Factor for
Angle Fractures? A Retrospective Cohort
StudyTevepaugh Dodson JOMS 1995 53646-649

• 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

37
Relationship between fractures of the mandibular
angle and the presence and state of eruption of
the lower third molarSafdar, BMedSci, Meechan
Oral Surg 199579680-684

• Results
• Significantly greater when unerupted M3 were
  present
• Bilateral unerupted M3 predisposed to a fracture
  at the angle significantly more than unilateral
  unerupted M3
• Peterson (1991)
• Prophylactic extraction of unerupted M3 sports

38
Incompletely erupted third molars in the line of
mandibular fractures A retrospective analysis
of 57 casesMarker, Eckerdal et al Oral Surg
199478426-31
39
(No Transcript)
40
Clinician variablility in characterizing mandible
fracturesShetty, Atchison, Belin, Wang JOMS
59254-261, 2001
41
A Biomechanical Evaluation of Mandibular Angle
Fracture Plating TechniquesHaug et al JOMS
2001 591199-1210

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

42
A Biomechanical Evaluation of Mandibular Angle
Fracture Plating Techniques Haug et al JOMS
2001 591199-1210

• 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 period 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

43
Technique for Applying 2 Miniplates for Treatment
of Mandibular Angle FracturesChoi et al JOMS
2001 59353-354

• 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

44
Mandibular fractures in Townsville, Australia
incidence, aetioology and treatment using the 2.0
AO/ASIF miniplate systemSchon et al British
JOMS 2001, 39145-148

• 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

45
An effective technique for open reduction of
mandibualr angle fractures using new reduction
forceps technical innovationsChoi et al Int
JOMS 2001, 30555-557

• ???? reduction forcep? ???? ??? ??? ??
  complication ?? ? ??.
• Precompressing fractures? ? ????? ?????
  stability? healing? ??? ??.
• 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

46
Treatment of Mandibular Angle Fractures with a
Malleable Noncompression MiniplatePotter
Ellis JOMS 1999 57288-292

• Purpose
• Single, thin, malleable miniplate? ??? ?? ??? ??
• 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 recommended for routine

47
Treatment of Mandibular Angle Fractures with a
Malleable Noncompression Miniplate Potter
Ellis JOMS 1999 57288-292

• 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

48
Treatment methods for fractures of the mandibular
angleEllis Int JOMS 1999, 28243-252

• Angle fracture? ??? ???? ??
• The presence of third molars
• A thinner cross-sectional area than the
  tooth-bearing region
• Biomechanically the angle can be considered a
  lever area
• Treatment methods ? slide? ?? ?
• Most useful AO/ASIF or single miniplate

49
Treatment methods for fractures of the mandibular
angleEllis Int JOMS 1999, 28243-252

• 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

50
Biomechanical evaluation of new fixation devices
for mandibular angle fracturesWittenberg et
al Int JOMS 1997, 2668-73

• Mandible angle fractures 2342 of all mandible
  fractures

51
One- or two-plate fixation of mandibular angle
fractures?Schierle, Schmelzeisen, Rahn,
Pytlik J.CMS 1997, 25162-168

• Summary
• No significant difference
• Two plate fixation may not offer advantages over
  single plate fixation in general
• 2 plates more rigid fixation

52
Photoelastic analysis of miniplate osteosynthesis
for mandibular angle fracturesRudman et al
Oral Surg 1997, 84129-36
53
Relative displacement resistance of standard and
low-profile bone plates in experimental
mandibular angle fracturesNissenbaum Oral Surg
1997, 83427-32

• ??? ? ?? ??? ? mm ?????

54
A comparison of mandibular angle fracture plating
techniquesHaug et al Oral Surg 1996, 82257-263

• 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

55
Treatment of Mandibular Angle Fractures Using One
Noncompression MiniplateEllis et al JOMS 1996
54864-871

• Purpose
• Single miniplate? ?? ??? ??? ??
• Patients and Methods
• 81 patients OR/IF using one noncompression
  miniplate with 2.0mm 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

56
Treatment of Mandibular Angle Fractures Using One
Noncompression Miniplate Ellis et al JOMS
1996 54864-871

• 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

57
Treatment of Mandibular Angle Fractures Using One
Noncompression Miniplate Ellis et al JOMS
1996 54864-871

• 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 miniplate
  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

58
Treatment of Mandibular Angle Fractures Using One
Noncompression Miniplate Ellis et al JOMS
1996 54864-871

• 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 Ellis (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

59
Lag-screw fixation of mandibular parasymphyseal
and angle fracturesKallela, Ilzuka et al Oral
Surg 1996, 81510-516

• 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

60
Stability testing of a two miniplate fixation
technique for mandibular angle fractures.An in
vitro studyChoi et al J. Cranio Maxillofac Surg
1995 23122-125

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

61
Fracture Line Stability as a Function of the
Internal Fixation System An In Vitro
Comparison Using a Mandibular Angle Fracture
ModelVivek Shetty et al 1995 JOMS 53791-801

• 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 adaptive systems
• And provide good immediate function stability to
  reduced mandibular angle fractures

62
Modified Technique for Adapting a Mandibular
Angle Superior Border PlateGerard 1995 JOMS
53220-221
63
A Microplate and Screw Technique for Intraoral
Open Reduction of Mandibular Angle FracturesHaug
1995 JOMS 53218-219

• 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 4.05.0 mm in length, monocortical
• 6 weeks MMF
• Titanium
• More cost

64
Clinical and in vitro evaluation of mandibular
angle fracture fixation with the two-miniplate
systemChoi et al Oral Surg 1995, 79692-5
65
Treatment of Mandibular Angle FracturePlate and
Screw FixationAssael 1994 JOMS 52757-761
66
Treatment of Mandibular Angle Fractures Using Two
Noncompression MiniplatesEllis 1994 JOMS
521032-1036

• 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 )
• lt 6 weeks 47
• 6-10 weeks 24
• gt 10 weeks 29
• Conclusions
• 2 noncompression miniplate was easy, but resulted
  in an unacceptable rate of infection

67
Treatment of Mandibular Angle Fractures Using Two
Noncompression MiniplatesEllis 1994 JOMS
521032-1036

• 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 complication

68
Treatment of Mandibular Angle Fractures Using Two
Noncompression MiniplatesEllis 1994 JOMS
521032-1036

• 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

69
Treatment of Mandibular Angle FracturesTransoral
Internal Wire FixationMarciani, Anderson, Gonty
1994 JOMS 52752-756

• 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

70
Bite Forces in Patients Treated for Mandibular
Angle Fractures Implications for Fixation
RecommendationsTate, Ellis 1994 JOMS 52734-736

• 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

71
Rigid internal fixation of fractures in the
angular region of the mandible An analysis of
factors contributing to different
complicationsIizuka, Lindqvist PRS 1993, 91265
72
Treatment of mandibular angle fractures using the
AO reconstruction plateEllis JOMS 1993,
51250-254
73
Complications of nonrigid fixation of mandibular
angle fracturesPasseri, Ellis, Sinn JOMS 1993,
51382-384
74
Treatment of mandibular angle fractures using two
2.4-mm dynamic compression platesEllis JOMS
1993, 51969-973
75
Treatment of mandibular angle fractures using two
mini dynamic compression platesEllis JOMS 1992,
50958-963
76
Biomechanical validation of the solitary lag
screw technique for reducing madibular angle
fracturesShetty Caputo JOMS 1992, 50603-607
77
Single oblique lag screw fixation of mandibular
angle fracturesFarris, Dierks laryngoscope
1992, 1021070-1072
78
Screw-wire osteosynthesis technique for intraoral
open reduction of mandibular angle fracturesDym,
Coro, Ogle JOMS 1992, 501247-1248
79
Lag screw fixation of mandibular angle
fracturesEllis JOMS 1991, 49234-243
80
(No Transcript)
81
A Computer Study of Biodegradable Plates for
Internal Fixation of Mandibular Angle
FracturesTams, Loon, Otten, Bos JOMS 2001
59404-407

• Purpose
• Suitability of small biodegradable plate systems
• Materials Methods
• 2 polylactide(PLA) midiplates
• 2 PLA maxiplates
• 1st fixation external oblique ridge? 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

82
A Computer Study of Biodegradable Plates for
Internal Fixation of Mandibular Angle
FracturesTams et al. JOMS 2001 59404-407

• 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

83
The Efficacy of Bioresorbable Fixation in the
Repair of Mandibular Fractures An Animal
StudyQuereshy et al JOMS 2000 581263-1269

• 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 mandibular angle fractures in a dog
  model

84
The Efficacy of Bioresorbable Fixation in the
Repair of Mandibular Fractures An Animal Study
Quereshy et al JOMS 2000 581263-1269

• 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

85
A computer study of fracture mobility and strain
on biodegradable plates used for fixation of
mandibular fracturesTams et al JOMS 1999,
57973-981
86
CASE REPORT

• 19972002

87

• 1997 2002
• 110 Patient
• 21 ?? ??????? 4? ??
• 1 ?? ?????? closed reduction
• ???? 26.7 ? (
• ?? 85?, ?? 25?
• ?? 69?, ?? 41?
• Isolated fx 56 ?, combine fx 54 ? (condyle head
  1?)
• Without M3 6?, with M3 104?
• ??? 85?, ?? 19?
• ??? ???? ?? 6? ?? (1?19?)
• ??? ???? ?? 4? ?? (1?19?)
• ??? ???? ?? 7.26? ??(2?18?)
• 4??? ??????? ?? ??? 7??(1??45??)
• 1? ?? ?? ?? ?? 88?? 54? ?????
• 5.7?? ??