Central Annals of Otolaryngology and Rhinology

Cite this article: Rout SK, Singh S, Mantry S (2017) Miniplate Fixation of Mandible Fractures Plus 2 Weeks of Intermaxillary Fixation - A prospective study. Ann Otolaryngol Rhinol 4(2): 1164.

*Corresponding author

Sunil Kumar Rout, Department of Plastic Surgery, Kalinga Hospital ltd, A-104, Infocity Greens Appartment, Sailashree Vihar, Bhubaneswar, Orissa, PIN: 751021, India, Tel: 91-9937176025; Email:

Submitted: 23 June 2016

Accepted: 20 March 2017

Published: 21 March 2017

ISSN: 2379-948X

Copyright© 2017 Rout et al.

OPEN ACCESS

Keywords•Mandible•Miniplate•Intermaxillaryfixation

Research Article

Miniplate Fixation of Mandible Fractures Plus 2 Weeks of Intermaxillary Fixation - A prospective studySunil K. Rout1*, Subhendu Singh2, and Sanujeet Mantry3

1Department of Plastic Surgery, Kalinga Hospital ltd, India2Department of Oral & Maxillofacial Surgery, Kalinga Hospital ltd, India3Department of Dental Sciences, Kalinga Hospital ltd, India

Abstract

Purpose: A prospective study of patients being treated for fracture mandible with miniplate fixation plus two weeks of Intermaxillary fixation was designed. The purpose of this study was to establish the better outcome with this technique mainly in terms of occlusion, good osteosynthesis and lesser complication.

Patients and Methods: From April 2010 to June 2013 we treated 31 patients who fit to the laid down criteria. They had a total of 42 fractures in their mandible. The fractures were fixed with 2.0 mm non-locking miniplates and screws as per the Champy’s principles of ideal osteosynthesis. It was supplemented by 2 weeks of Intermaxillary fixation post operatively. They were followed up for a minimum period of 6 weeks. The outcome was assessed in terms of occlusion, implant site infection and mouth opening.

Results: Only one of these patients (3%) ended up with a poor occlusion which would require a surgical correction. All of them had adequate (> 3.0cm) inter-incisor opening by the end of their treatment and 3 of them (9.6%) developed infection at the implant site which could be managed with antibiotics and local wound care.

Conclusion: Supplemental IMF for 2 weeks following miniplate fixation along the Champy’s lines of osteosynthesis yields better outcome in cases of fracture mandible.

INTRODUCTIONTreatment of jaw fractures has evolved through a long

journey from history to present time. In older days it was primarily conservative, comprising bandages of different nature and design. Intermaxillary fixation and inter-osseous wiring introduced by Gilmer in 1887, occupied the center stage of treatment of these fractures in the early part of twentieth century1. But this treatment has obvious disadvantages of significant weight loss, nutritional impairment, poor oral hygiene and temporomandibular joint ankylosis. During the last quarter of the century internal fixation of jaw fractures was popularized using semi-rigid and rigid fixation techniques with 1.5 to 2 millimeter miniplates and 2.5 millimeter locking plates respectively [1-3]. Later techniques enjoyed the advantage of early return to daily activities and minimal susceptibility to develop temporomandibular joint ankylosis. Intermaxillary fixation still has an important role adopted for a shorter period

at least, when supplemented to miniplate fixation [4-9]. Though many authors disapprove the continuation of mandibulao-maxillary fixation to post operative period, some observed the use IMF as a primary modality of treatment in a good number of such patients [10-12].

We designed this prospective study to establish the advantages of supplemental 2 weeks IMF following miniplate fixation of fracture mandible according to Champy’s principle

[13,14].

PATIENTS & METHODSA prospective study was conducted in our hospital which is

a tertiary care center situated in our state capital. The patients treated for fractures of mandible during the period from April 2010 to June 2013 were included in this study after obtaining ethical approval from the IRB of our hospital. The unconscious, epileptic, uncooperative patients and those who had comminuted

Central

Rout et al. (2017)Email:

Ann Otolaryngol Rhinol 4(2): 1164 (2017) 2/3

fractures or fracture of mandibular condyle alone were excluded from this study.

After the patients being anaesthetized with nasotracheal intubation, fracture fragments were reduced and brought into occlusion by intermaxilary fixation. All these patients underwent internal fixation using titanium miniplates and screws (2.0 mm system) along the Champy’s lines of osteosynthesis. The wounds were closed with absorbable sutures and the IMF was maintained for a period of 2 weeks. During the later part of this study the practice was changed. The mouth was opened immediately after the bone plating and wound closure to avoid the possible risk of post anaesthesia period complication. This is done by removing the secondary tie wires only, leaving the Erich’s arch bars in place. Secondaries are tied in occlusion on third post operative day and kept for 2 weeks. All the patients were followed up for a minimum period of 6 weeks to assess the outcome in terms of occlusion, mouth opening, and infection. Post operative occlusion was classified into three categories - (a) good - if it is normal (b) fair- which required minimal occlusal treatment to achieve normal occlusion and (c) poor - those required subsequent surgery to get back the normal occlusion.

OBSERVATION31 patients received treatment for fracture mandible during

this period fit to the criteria chosen, and included in this study. They had a total of 42 fractures in their mandibles. Age of these patients ranged from 17 to 56 years, the mean being 29.35 years. Most of the patients (48.38 %) were in their 3rd decade of life (Table 1). 29 of them (93.5 %) were male and only 2 (6.5 %) females. After being hospitalized only 2 of them were treated surgically within 48 hours. Most of them (51.6 %) were operated within 3 to 5 days. 13 patients (41.9 %) required longer time to be stabilized haemodynamically and neurologically, and had more than 5 days waiting time before surgery. The mean interval between trauma and surgery was 6.8 days. As per the anatomical distribution of fractures, parasymphyseal and symphyseal fractures constituted majority of them (66.6 % in total), angle of mandible in 6 (14.3 %), condyle in 5 (11.9 %), ramus in 2 (4.8 %) and body of mandible in 1 (2.4 %) of the patients (Table 2). 5 of these patients had associated injuries in extremities, 3 intracranial injuries, 2 thoracic and in another 2 of them eyes were affected. Fractured bones were fixed by 2.0 mm titanium miniplates and screws. 22 patients were followed up for a period of 6 weeks and rest of them (9 patients) beyond this period. The average follow up period was 11 weeks, ranging from 6 weeks to 18 months.

24 of them (77.5 %) had good occlusion. 6 (19.3 %) had fair and only 1 patient (3 %) ended up with poor occlusion (Table 3). Mouth opening was achieved 3 to 4.5 cm in 17 (54.8 %) of these patients. Rest 14 (45.2 %) had more than 4.5 cm inter – incisor opening (Table 4). None of them had a poor mouth opening (less than 3.0 cm). Among other complications implant site infection was evident in 3 patients (9.6 %).

DISCUSSIONOver a period of time miniplate fixation has evolved as the

preferred method of treatment for maxillofacial fractures. It took away the disadvantages of Intermaxillary fixation for a

considerable length of time like weight loss, TM joint stiffness and poor oral hygiene. Miniplate fixation is not suitable for the comminuted and infected fractures because they need a stable fixation not allowing any movement during function. These fractures need to be fixed rigidly by thick locking reconstruction plates and 2.5 mm screws. Miniplate fixation of mandibular fractures along the Champy’s lines of ideal osteosynthesis, is practically semi-rigid and provides a functional stability. Intra-operatively before fixing the fractures with plates and screws both the alveolar arches are brought into occlusion by different techniques. The mouth is opened after the plating of fractures. During the early post operative period there is a chance for displacement of the fracture segments if subjected to strong external forces, because of the semi-rigid nature of this fixation. Hence supplemental IMF for a brief period (2 weeks) following miniplate fixation secures the reduction of fracture fragments that is achieved intra-operatively. The finding of our study with young male individuals being the most common victims of such injury (mean age 29.35 years) is in between those of Van Den

Table 1: Age distribution of the patients.Age group (in years) No. of cases

0 – 10 011 – 20 6 (19.35 %)21 – 30 15 (48.38 %)31 – 40 5 (16.12 %)41 – 50 2 (6.45 %)51 – 60 3 (9.67 %)

>61 0Total 31

Table 2: Part of the mandible fractured.

Fracture site No. of cases

Parasymhyseal 17 (48.47 %)

Symphyseal 11 (26.2 %)

Condyle 5 (11.9 %)

Angle 6 (14.3 %)

Body 1 (2.4 %)

Ramus 2 (4.8 %)

Total 42

Table 3: Occlusion in follow up patients.

Occlusion Number (percent )

Good 24 (77.5 %)

Fair 6 (19.3 %)

Poor 1 (3 %)

Table 4: Mouth opening –Inter Incisor Distance.

Mouth opening Number (percent)

< 3 cm 0

3.0 – 4.5 cm 17 (54.8 %)

> 4.5 cm 14 (45.2 % )

Central

Rout et al. (2017)Email:

Ann Otolaryngol Rhinol 4(2): 1164 (2017) 3/3

Bergh B et al (32.6 years) and Mehra P & Murad H (24.8 years) [15,16].

Our main focus was on occlusion in this study and we got poor occlusion in only one patient (3% of our patient population). Malocclusion was found in 3.4% in plating only & 2.5 % & in IMF only in the series of Zachariades et al, [17]. It was 1 to 3 % in the series of Renton & Wiesenfeld (more in non – Champy’s and trans-osseous wire fixation group) and 2.9% (1 of 34 patients) with Chritah et al (5, 7). The incidence was 3.38% (2 of 59 patients) with Ellis & Graham (13) and 4.4% (2 of 45) in MMF group of Kumar et al and 6.6 % (15 of 225 patients) with Van Den Bergh (9, 15). Hence the outcome of our series in terms of occlusion is at par with the findings of the above authors. The incidence of malocclusion in our study is very low in comparison to that of Daif and Emad T (32 %) [18].

We had infection in 3 (9.6%) of our patients which is relatively low in comparison to the findings of Renton et al (11%), Daif and Emad T (21 %) and Ellis et al (10%) [5,18,19]. Whereas the incidence is high as compared to those of Bolourian (6.45%), Chritah (0%), Kumar (6.6% in MMF group), Van Den Bergh (2.67 %) and Zachariades (3.4 and 3.5 % in plating and IMF cases respectively), [6,7,9,15,17]. Restriction of mouth opening was not reported in any of these studies. It was included in our study and the inter-incisor distance was recorded. All of our patients achieved mouth opening more than 3 cm.

We had major complications in 12.9 % of our total patient population. This is much less than those of Valentino J et al (17 %), Kumar I et al (17 %), and similar to that of Van Den Bergh B et al (11.5 %) [4,9,15].

CONCLUSIONMiniplate fixation of mandibular fractures provides

functional stability to the jaw. There remains a possibility for displacement of the fractured bone segments to some extent. Supplemental Intermaxillary fixation for a brief period (2 weeks) following miniplate fixation provides better stability to the mandible during the early phase of bone healing. This technique helps to achieve better outcome in terms of occlusion and at the same time does not add to the operative time, cost of the treatment and other morbidities. Hence miniplate fixation as per the principle of Champy and supplemental IMF for 2 weeks is a better modality to manage the mandibular fractures as evident from this prospective study.

REFERENCES1. Gilmer TL. A case of fracture of the lower jaw with remarks on

treatment. Archives of dentistry. 1887; 4: 388.

2. Spiessl B. New concepts in maxillofacial bone surgery. Springer Verlag. 1976.

3. Michelet FX, Deymes J, Dessus B. Osteosynthesis with miniaturized screwed plates in maxillo-facial surgery. J Maxillofac Surg. 1973; 1: 79-84.

4. Valentino J, Marentette LJ. Supplemental maxillomandibular fixation with miniplate osteosynthesis. Otolaryngol Head Neck Surg. 1995; 112: 215-20.

5. Renton TF, Wiesenfeld D. Mandibular fracture osteosynthesis: a comparison of three techniques. Br J Oral Maxillofac Surg. 1996; 34: 166-173.

6. Bolourian R, Lazow S, Berger J. Transoral 2.0-mm miniplate fixation of mandibular fractures plus 2 weeks maxillomandibular fixation: A prospective study. J Oral Maxillofac Surg. 2002; 60: 167-170.

7. Chritah A, Lazow S, Berger J. Transoral 2.0-mm locking miniplate fixation of mandibular fractures plus 1 week of maxillomandibular fixation: A prospective study. J Oral Maxillofac Surg. 2005; 63: 1737-1741.

8. Longwe EA, Zola MB, Bonnick A, Rosenberg D. Treatment of mandibular fractures via transoral 2.0-mm miniplate fixation with 2 weeks of maxillomandibular fixation: A retrospective study. J Oral Maxillofac Surg. 2010; 68: 2943-2946.

9. Kumar I, Singh V, Bhagol A, Goel M, Gandhi S. Supplemental maxillomandibular fixation with miniplate osteosynthesis. Oral Maxillofac Surg. 2011; 15: 27-30.

10. El-Anwar MW, El-Ahl MAS, Amer HS. Open Reduction and Internal Fixation of Mandibular Fracture without Rigid Maxillomandibular Fixation. Int Arch Otorhinolaryngol. 2015; 19: 314-318.

11. Khiabani KS, Mehmandoost MK. Transoral Miniplate Fixation of Mandibular Angle Fracture with and without 2 Weeks of Maxillomandibular Fixation: A Clinical Trial Study. Craniomaxillofac Trauma Reconstr. 2013; 6: 107-114.

12. Boffano P, Kommers SC, Roccia F, and Forouzanfar T. Mandibular trauma treatment: A comparison of two protocols. Med Oral Patol Oral Cir Bucal. 2015; 20: 218-223.

13. Champy M, Lodde JP: Mandibular synthesis. Placement of the synthesis as a function of mandibular stress. Rev Stomatol Chir Maxillofac. 1976; 77: 971-976.

14. Champy M, Loddé JP, Schmitt R, Jaeger JH, Muster D. Mandibular osteosynthesis by miniature screwed plates via a buccal approach. J Maxillofac Surg. 1978; 6: 14-21.

15. Van Den Bergh B, Heymans MW, Duvekot F, Forouzanfar T. Treatment and complications of mandibular fractures: A 10-year analysis. J craniomaxillofac surg. 2012; 40: 108-111.

16. Mehra P. Murad H. Internal Fixation of Mandibular Angle Fractures: A Comparison of 2 Techniques. J Oral maxillofac Surg. 2008; 66: 2254-2260.

17. Zachariades N, Mezitis M, Rallis G. An audit of mandibular fractures treated by intermaxillary fixation, intraosseous wiring and compression plating. Br J Oral Maxillofac Surg. 1996; 34: 293-297.

18. Daif, Emad T. Correlation of plates number with complications of osteosynthesis in mandibular fractures. Journal of Craniofacial Surgery. 2014; 25: 526-529.

19. Ellis E, Graham J. Use of a 2.0-mm locking plate/screw system for mandibular fracture surgery. J Oral Maxillofac Surg. 2002; 60: 642-646.

Rout SK, Singh S, Mantry S (2017) Miniplate Fixation of Mandible Fractures Plus 2 Weeks of Intermaxillary Fixation - A prospective study. Ann Otolaryngol Rhinol 4(2): 1164.

Cite this article