Ma ndib le F r actures

Discussion and Debate

Oneida Arosarena, MDa,*, Yadranko Ducic, MD, FRCS(C)b,c,*,
Travis T. Tollefson, MD, MPHd,*

KEYWORDS
 Mandible fracture repair  Miniplates  Maxillomandibular fixation  Panel discussion

Mandible Fractures Panel Discussion

Oneida Arosarena, Yadro Ducic, and Travis T. Tollefson address questions for discussion and debate:
1. Is rigid fixation essential for the treatment of angle fractures, or is a single plate along the superior
border sufficient?
2. Does the presence of teeth in the fracture line (particularly the third molar in angle fractures)
contribute to stability of the fixation, or is it a nidus for infection?
3. What is the role of postoperative antibiotics? Are they always necessary?
4. Do you believe that applying MMF is an important part of mandibular fracture repair? If you do not
use MMF in all cases, how do you decide which cases require intraoperative and/or postoperative
MMF? Do you believe that the techniques/methods of applying MMF make a difference?
5. How do you manage edentulous mandible fractures?
6. Analysis: Over the past 5 years, how has your technique or approach changed or what is the most
important thing you have learned in dealing with mandible fractures?

Is rigid fixation essential for the treatment of angle fractures, or is a single

plate along the superior border sufficient?
AROSARENA
Because of the biomechanics of the mandible, Philosophy 1. The goal of the first group is rigid
mandibular angle fractures have a high incidence fixation with 2 miniplates resulting in primary bone
of postsurgical complications. There are currently union, which necessitates absolute immobility of
2 philosophies espoused by practitioners who the fracture fragments according to older Arbeits-
use open reduction and internal fixation (ORIF) in gemeinschaft für Osteosynthesefragen–Associa-
the treatment of mandibular angle fractures. tion for the Study of Internal Fixation guidelines.

a
Department of Otolaryngology–Head and Neck Surgery, Temple University, 3440 North Broad Street, Suite
facialplastic.theclinics.com

300, Philadelphia, PA 19128, USA

b
Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center,
Dallas, TX, USA
c
Otolaryngology and Facial Plastic Surgery Associates, 923 Pennsylvania Avenue, Suite 100, Fort Worth, TX
76104, USA
d
Cleft and Craniofacial Program, Otolaryngology–Head and Neck Surgery, Facial Plastic and Reconstructive
Surgery, University of California, Davis, 2521 Stockton Boulevard, Suite 7200, Sacramento, CA 95817, USA
* Corresponding authors.
E-mail addresses: [email protected]; [email protected]; [email protected]

Facial Plast Surg Clin N Am 20 (2012) 347–363

doi:10.1016/j.fsc.2012.05.001
1064-7406/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
348 Arosarena, Ducic, Tollefson

Philosophy 2. The second group advocates the account the stabilizing effects of surrounding
use of a single miniplate along the ideal line of os- tissues, particularly muscles.5,8 Moreover, these
teosynthesis as described by Champy. Although models do not take into account the possibility of
this method does not result in rigid fixation, its stress shielding in the healing mandible that could
proponents list benefits of decreased soft-tissue be attributed to rigid fixation.8,9
stripping that maintains blood supply to the In a prospective, randomized trial of 54 patients
mandible, the lack of an external incision, and with unilateral, isolated mandibular angle frac-
cost savings related to decreased operative time tures, Danda10 found that the use of 2 noncom-
and savings in hardware.1 Because bite forces pression miniplates had no advantage over the
do not return to premorbid levels for several weeks use of 1 superior border plate, and that the use
after fracture treatment, proponents of the Cham- of 2 miniplates resulted in scarring at the transcu-
py technique argue that absolute rigid fixation may taneous incision in 18% of patients. However,
not be necessary for angle fractures.2 Danda used 2 weeks of interdental fixation in all
Several biomechanical studies have demon- patients. Similarly, in a study of 185 patients
strated that the Champy technique has less favor- with isolated unilateral angle fractures, Ellis1
able biomechanical behavior than biplanar plating found no significant difference in treatment
techniques.3–7 Two studies revealed that a 3-dimen- outcomes for patients treated with rigid versus
sional plate at the superior border of the mandible re- nonrigid fixation, although patients treated with
sulted in increased stability with torsional loading rigid fixation in this study had longer operative
when compared with other commonly used times and more wound problems. A recent
mandibular angle fixation techniques, effecting bi- meta-analysis of mandibular angle fixation tech-
planar fixation with a single plate.3,6 However, these niques found lower complication rates with the
studies may represent oversimplified depictions of use of 1 superior border plate compared with
fractured mandible biomechanics, not taking into the use of 2 plates.11

DUCIC
The decision as to which method of fixation is angle fractures is needed in comminuted frac-
most appropriate will, of course, be determined tures. Compression plating and lag screw fixa-
by the specific type of injury present. There are tion is not appropriate in these circumstances,
several options in treating these injuries with because of the potential for fragmentary tele-
respect to fixation modality. Closed reduction is scoping. Studies performed in noncomminuted
still an option. However, there is a prolonged angle fractures demonstrate a decreased risk of
period of immobilization that may be associated complications with a single superior border
with increased rate of long-term temporoman- monocortical miniplate placed along Champy’s
dibular joint problems. Closed reduction is rela- ideal line of osteosynthesis, slightly greater
tively contraindicated in comminuted angle complication rate with an inferior border bicorti-
fractures because of the increased risk of cal plate, and the greatest rate of complications
complications. Rigid load-bearing plating of with 2 separate plates.1–5

TOLLEFSON
In treatment of fractures of craniomaxillofacial 2-plate fixation. He cited fewer complications
skeleton, is it not rigid truth that 2 plates are better and shorter operative time. I concur with the appli-
than 1? Unfortunately, the relationship of bioengi- cation of a single plate at the mandibular oblique
neering concepts to the clinical application of rigid line for treatment of angle fractures in the following
fixation is not as linear as we would expect. Prac- circumstances:
tice patterns in mandible fracture management
have steadily evolved over the last century, with 1. Adequate bone stock is available
surges of major advances from both bioengi- 2. Comminution or bone defect (eg, gunshot
neering and clinical fields. Ellis1 recently reported wound) is not present
superiority of the single miniplate technique for 3. Nonedentulous
mandibular angle fractures over either maxillo- 4. In the presence of adequate dentition to restore
mandibular fixation after closed reduction or occlusion.
 Mandible Fractures 349

Fig. 3. Following ORIF of both fractures, note persis-

tent lack of reduction at left angle fracture, due to
retention of the impacted third molar.

to his expansion on the work of Michelet

(Fig. 1).2 The former, adapted from Association
for Osteosynthesis/Association for the Study of
Internal Fixation (AO-ASIF) orthopedic manage-
Fig. 1. Mandibular angle fracture open reduction and
ment principles of long bone fractures, is sup-
internal fixation with a single miniplate on the obli-
que line. ported because of the establishment of rigid
fixation for primary bone healing by limiting motion
around the fracture (Figs. 1–4).3
Conflicting clinical outcomes have been reported
I will briefly introduce the state of the science by using principles of either school, but the fracture
reviewing the theories of rigid versus adaptive fixa- site, complexity of the forces applied to the frac-
tion and the reports of the outcomes of their ture, and independent patient characteristics
application. must be considered. Ellis and Walker4 reported
Without considering the extremes of treatment on angle fracture fixation with 2 miniplates, but later
trends, the contemporary history of mandible frac- suggested a lower complication rate with a single
ture treatment paradigms can be simplified into 2 miniplate.5 The investigators partially attributed
different schools: this difference to the additional dissection needed
for the second plate. Fox and Kellman6 contrasted
1. Treatment patterns restricting function and this report with a 2.9% complication rate in 70 angle
movement (with external fixation, wires, and fractures treated with 2 monocortical miniplates,
load-bearing internal fixation)
2. Shift to near immediate return to function with
limited, site-directed internal plate fixation.
The latter incorporates the concept of adaptive
osteosynthesis, which has come to be colloquially
referred to as the Champy technique in reference

Fig. 2. Preoperative Panorex demonstrating right Fig. 4. 3D CT Scan image of demonstrating exposure of
body and left angle fractures. Note presence of the left third molar in the left mandibular angle frac-
impacted third molar in fracture line. ture. A right parasymphyseal fracture is also present.
350 Arosarena, Ducic, Tollefson

and also clarified that the 1994 Ellis and Walker with the relative success using either 1 or 2 mini-
study included bicortical application of the inferior plates on the mandibular angle. I strongly concur
border plate. As with any comparative effective- with Rudderman and colleagues in that fixation
ness research, a direct, randomized prospective should “provide for a functional construct that
study of sufficient power would be ideal, but is can adequately heal while the patient participates
unlikely. It is plausible that these contrasting clinical in near normal activities.”37 It may seem contradic-
experiences may be clarified by studying outcomes tory to suggest that less fixation is better in some
in a multi-institutional database with sufficient circumstances, but applying functionally stable
collection of fracture details and related secondary fixation while allowing dental loads to be applied
factors of bone healing, such as soft-tissue dissec- to the healing mandible may improve bone
tion, approaches, technique, and duration of max- density, as described by Julius Wolff in 1892 in
illomandibular fixation, and the general patient’s the law of transformation of bone.7 The 1-plate
general “protoplasm” or health (eg, diabetes, alco- technique on the oblique line is my preference
holism, malnutrition, tobacco abuse). for the uncomplicated mandibular angle fracture
Although the contrasting clinical reports can be because it adequately minimizes interfragmentary
difficult to directly compare, I am comfortable movement via a limited soft-tissue dissection.

Does the presence of teeth in the fracture line (particularly the third molar
in angle fractures) contribute to stability of the fixation, or is it a nidus for
infection?
AROSARENA
The prophylactic removal of teeth in the line of mandible, which may reduce the stability of osteo-
fracture was advocated before the widespread synthesis and cause micromobility after fixation.16
use of antibiotics and rigid internal fixation, both Extraction of viable teeth may induce additional
of which have significantly reduced the infection trauma to the adjacent bone and destabilize the
rate associated with repair of mandible frac- fracture. In addition, healthy retained teeth provide
tures.15,16 Retained teeth historically were a posterior stop, permit proper alignment of the
believed to act as foreign bodies, providing dental arch, and prevent collapsing or telescoping
communication between the oral cavity and the of the fragments. Moreover, a normal coagulum
periodontal space. The trend over time has does not always form after tooth extraction, occa-
been retention of viable teeth in the fracture sionally leading to alveolitis and wound infec-
line.12,15–19 tion.12,16 According to Spinnato and Alberto,18
Ellis20 reported a trend toward increased conditions for preserving teeth in the fracture line
complication rates when molars, particularly the are antibiotic therapy, strict oral hygiene, radio-
third molar, are involved in the fracture line. logic and clinical monitoring for evidence of peri-
However, at least 3 retrospective series demon- apical infection and pulp necrosis, and
strated no difference in outcome of fracture endodontic therapy for teeth that require treat-
management whether the teeth were routinely ex- ment. Widely accepted indications for removal of
tracted or retained, and regardless of whether the the teeth in the line of fracture include12,16,18:
fracture was in the anterior or posterior denti-
tion.17,19,21 The third molar may represent  Significant periodontal disease with gross
a different situation because it is in a region where mobility and periapical pathology
debris tends to collect. In a retrospective analysis  Partially erupted or erupted third molars
of 105 mandible fractures associated with incom- with pericoronitis or cystic areas
pletely erupted third molars, Rubin and  Teeth preventing the reduction of fractures
colleagues22 found a trend toward increased  Teeth with fractured roots
complication rates in cases treated with open  Teeth with exposed root apices or teeth in
reduction when the third molar was retained. Other which the entire root surface from the
investigators recommend retention of healthy third apex to the gingival margin is exposed
molars that do not interfere with fracture reduction,  Excessive delay from the time of fracture to
particularly unerupted third molars. They argue the time of definitive treatment
that extraction of the third molar reduces contact  Recurring abscess at the fracture site
area in the already thin angular region of the despite antibiotic therapy.
 Mandible Fractures 351

DUCIC
The presence of a third molar doubles the risk of and a tooth preventing adequate fracture reduc-
mandible fracture because of the sheer volume of tion. This latter scenario is most often seen with
bone it occupies, effectively diminishing the a preoperatively impacted third molar (Figs. 2
height of the remaining mandible.6 There does and 3). If none of these criteria are met then
exist some controversy as to the need for third one may consider retaining the tooth based on
molar extraction in the setting of mandibular intraoperative factors. Removing third molars
angle fractures. Indications for removal are may further diminish the amount of bone remain-
generally accepted to include the presence of ing across the fracture site and may make the
a fractured tooth, a carious tooth, grossly loose stability of the reduction less stable; this is an in-
or displaced tooth, an impacted third molar that traoperative decision. Several studies support
would meet criteria for removal on its own merit, this approach.7

TOLLEFSON
Controversy persists over whether to remove removing teeth in the line of a fracture did not
a third molar that is in a mandibular angle fracture change infection rates. The investigators included
line. Before the advent of antibiotics, infections in other tooth-bearing fracture locations in the
fractures along the tooth-bearing mandible were studies, so we must infer how the angle fractures
common. Tooth extraction from the fracture site would behave. Iizuka and Lindqvist15 went further
theoretically decreased bacterial load, but the to suggest that tooth extraction can contribute to
advent of antibiotics shifted the paradigm.8 My postoperative infection. These investigators
practice is to retain healthy, erupted molars in purport that the tooth extraction may make the
mandibular angle fractures with the exception of fracture site unstable because of diminished bone
the indications that I will further describe. stock, whereas retaining a tooth may add to
As infection-related complications decreased stability. In a later study of 121 angle fractures,
with the routine use of preoperative and perioper- infection risk was higher after tooth extraction in
ative antibiotics, surgeons began to sort through the fracture line and when compression plate tech-
the effectiveness of different practice patterns: nique was used.16 The latter practice is now rare.
tooth extraction, duration of maxillomandibular The support for routine third molar extraction
fixation, rigid versus adaptive osteosynthesis, from the fracture line is less convincing. In 1964,
and surgical approaches. The debate over third Muller17 supported extraction of teeth with multiple
molar extraction in angle fractures excludes an roots from fracture lines. Ellis18 recently reviewed
abscessed or severely decayed tooth, which 400 cases in which third molar extraction from the
should be extracted in fractures of any area of angle fracture was routine practice. Third molars
the mandible. This clinical debate is also partially in the fracture line were present in 85% of the frac-
fueled by the routine practice of preventive extrac- tures, and 75% of these teeth were removed.
tion of third molar or wisdom teeth, which have Although the difference in infection and
had evolving indications and justifications in the
oral surgery literature.9
Third molars, occupying significant cross-
sectional area of the mandibular angle, have
been shown to predispose patients to up to 3.8
times the risk of angle fractures than those
without third molars.10–12 Once the fracture is
present, some surgeons choose to extract,
whereas others retain the third molar. I concur
with the theory that extraction of the third molar
from a fracture line may destabilize and limit the
interfragmentary buttressing required for bone
healing (Fig. 4).
The literature has support for both extraction and Fig. 5. 3D CT Scan image of demonstrating commi-
retention of the third molars in angle fractures. The nuted fracture of the left left mandibular angle
support in the literature for retention is strong. Neal fracture with resulting dental root fractures necessi-
and colleagues13 and Amaratunga14 found that tating extractions.
352 Arosarena, Ducic, Tollefson

complication rates failed to reach statistical signif- third molar in the mandibular fracture line except
icance, he concludes that the “difficulty that when the roots are fractured, (Fig. 5) severe dental
remains involves determining the appropriate caries and mobility are present, or in the presence
criteria for the removal of teeth in the line of of pericoronitis, abscess, or infection. If extraction
fracture.”18(p865) of the third molar is required, it can be removed
Determining the criteria for extraction remains after bone healing, as suggested by Iizuka and
challenging. My current practice is to retain the Lindquist.15,16

What is the role of postoperative antibiotics? Are they always necessary?

AROSARENA
Although the efficacy of perioperative antibiotics in A randomized, double-blind controlled trial by
the prevention of orthopedic fracture infections Abubaker and Rollert23 studied patients who
has been established, their use in the treatment of received postoperative penicillin for 5 days post-
mandibular fractures may not be comparable, due operatively in comparison with patients who
to the increased blood supply to the face but also received placebo. The study demonstrated no
because mandible fractures involving the tooth- benefits to the use of postoperative antibiotics,
bearing segments of the mandible are, by nature, but included only 30 patients. Other limitations of
contaminated wounds. Moreover, the use of post- this study were the exclusion of individuals with
operative antibiotics in some surgical disciplines immunocompromised states and exclusion of
has been associated with increased incidence of patients who were noncompliant with postopera-
postoperative infection attributed to the selection tive medications. Moreover, twice as many
of resistant organisms.23,24 The role of preoperative patients in the group receiving postoperative anti-
and intraoperative antibiotics in preventing postop- biotics than those receiving placebo were treated
erative infections in the treatment of mandible with closed reduction. All of the patients who
fractures involving dentate segments is estab- developed infections were treated with open
lished.24–26 However, the amount and quality of reduction. The investigators also noted that none
the existing data on the efficacy of prophylactic of the patients with fractures not involving the
postoperative antibiotics in cases of uncomplicated angle developed infections.23
mandible fracture repair is insufficient for formal In a randomized trial including 181 patients,
quantitative synthesis or meta-analysis.27 Miles and colleagues26 noted that of the patients
Only 9 randomized controlled trials have ad- who developed postoperative infections, the use
dressed the need for postoperative antibiotics after of postoperative antibiotics only delayed the time
repair of uncomplicated mandible fractures. These to presentation with infectious symptoms. In this
trials are limited by being underpowered, and most study the investigators included patients with
did not ensure allocation concealment.26,27 Also, comminuted fractures, used only open reduction/
several of the trials utilized various antibiotic regi- internal fixation for treatment, and found no benefit
mens and fracture treatment techniques, including to the use of postoperative antibiotics. However,
closed treatment, within the trial. In a systematic these results should be interpreted with caution
review of 6 of these trials, Andreasen and because the investigators reported a significant
colleagues24 determined that antibiotic prophy- attrition rate (38%), attributed to the patient popu-
laxis had no influence on the infection rate when lation (urban, low-income).26
fractures were treated by closed reduction, but In a retrospective study of patients treated for
significantly reduced the incidence of infection in uncomplicated mandible fractures where patients
patients treated with open reduction, because received a variety of antibiotic regimens for varying
open reduction increases contamination and time periods postoperatively (up to 10 days),
decreases blood supply to the injured site. None Lovato and Wagner28 found that the use of post-
of these studies supported the use of antibiotics operative antibiotics did not affect postoperative
beyond the first 48 postoperative hours.23,24,26 infection rates.

DUCIC
There remains a defined role for perioperative anti- fractures. Although postoperative antibiotics are
biotic therapy in the treatment of mandible widely as well, studies have not shown them to be
 Mandible Fractures 353

necessary or helpful in this patient population.8,9 In setting of a chronically infected mandible fracture
an acutely infected fracture, postoperative antibi- with osteomyelitis, a prolonged course of antibiotic
otics, covering usual oral pathogens including therapy that may extend as long as 6 weeks is
anaerobes, are generally recommended.10 In the recommended.

TOLLEFSON
To answer this question, we must clarify the current This difficult clinical question is fueled by conflict-
practice trends that differ by surgeon, geography, ing evidence from mostly experiential data that may
specialty, and even individual case. An infected not be generalizable. Kyzas28 recently called for
mandible fracture site demonstrating erythema, large, randomized controlled trials after performing
purulence, cutaneous fistula, or malunion/nonunion a systematic review of 31 studies, which included 9
is a clear indication for antibiotics. However, we randomized control trials and more than 5000
must consider the utility of the postoperative antibi- cases. This analysis failed to answer the question
otic course, especially involving fractures of the of the effectiveness of antibiotic use in mandible
dentoalveolar segments caused by the inherent fractures. Lovato and Wagner29 reported no differ-
oral bacterial contamination.20,22,23 ence in infection rate when patients with mandible
Antibiotic usage can by administered at different fractures were treated only perioperatively
time points in treatment, including time of diag- (13.33%) or for up to 7 days postoperatively
nosis, immediately preoperatively, for a 24-hour (10.67%). Of note, this case-control study of 150
postoperative period, and as extended postopera- cases included closed reduction cases, which
tive treatment (7–10 days). The doctrine of using of may have risks different to those of ORIF.
preoperative antibiotics given 1 hour before In reviewing the available literature, the retro-
surgery comes from the general surgery litera- spective approach has many limitations, not the
ture.26,27 Antibiotic prophylaxis for orthopedic least of which include a lack of consistent data
fractures are often discontinued within 24 hours collection. The ideal study would include the
postoperatively.24,25 The value of preoperative following factors:
antibiotics when the fracture involves a tooth-
1. Timing of surgery after injury
bearing segment is strongly supported.23,29 The
2. Site of mandible fractures (eg, decreased infec-
study by Zallen and Curry22 compared exposure
tion risk in non–tooth-bearing condylar and
to either no antibiotics or any antibiotics in open
ramus fractures)
and closed reduction treatments of a variety of
3. Type and dosage of antibiotic
mandible fracture locations, and they reported
4. Timing of antibiotic administration including
a strikingly higher infection rate in the nonantibiotic
presurgical, intraoperative, and postoperative
groups (50.33%) compared with receiving any
5. Duration of antibiotic course
antibiotic (6.25%). None of these studies provided
6. Surgical approach (external or intraoral)
specific information on the value of postoperative
7. Fixation technique (ORIF or closed reduction
antibiotics.
with maxillomandibular fixation).
Abubaker and Rollert21 designed a prospective,
double-blind, clinical study to investigate the Although multi-institutional, randomized control
effect of postoperative antibiotics. All patients trials would be valuable for antibiotics in facial frac-
received penicillin G perioperatively and for 12 ture treatment, the study design is often deemed
hours postoperatively while the second arm impractical or unfeasible. The best alternative
received additional penicillin VK orally for 5 days, comparative study would need to account for the
and the control group received placebo. The differences in patient demographics, health status,
investigators found that “postoperative oral antibi- tobacco and alcohol use, and dental health.
otics in uncomplicated fractures of the mandible My preference for antibiotic use will continue to
had no benefit in reducing the incidence of infec- include pre-, peri-, and postoperative as we await
tion.”21 These findings concur with those of Furr potential definitive, future studies that may include
and colleagues,19 who also noted no difference more of the 7 factors listed above. My protocol
in those cases that had delayed treatment. includes giving antibiotics at the time of presenta-
However, alcohol and tobacco abuse was associ- tion until the repair, relaying on oral clindamycin or
ated with increased complications such as penicillin or intravenous clindamycin or cefazolin.
abscess, infection, nonunion/malunion, and hard- The dosage given an hour before surgery is given
ware exposure. It may be that algorithms for anti- intravenously and then repeated until conversion
biotic use will need to consider these as well as to the oral equivalent, which, along with 0.1%
other patient-specific risk factors. chlorhexidine rinses, is continued for 7 days.
354 Arosarena, Ducic, Tollefson

There seems to be a recent trend toward repairing mandible fractures

without applying MMF. Do you believe that applying MMF is an important
part of mandibular fracture repair? If you do not use MMF in all cases, how
do you decide which cases require intraoperative and/or postoperative
MMF? Do you believe that the techniques/methods of applying MMF make
a difference?
AROSARENA
While there is a trend toward repairing mandible typically use MMF if the mandible is edentulous or
fractures without applying maxillomandibular fixa- has so few teeth that occlusion cannot be estab-
tion (MMF), I believe that MMF is important in lished; in these cases I believe that dentures can
dentulous patients, to establish normal occlusion be adjusted to address postoperative malocclu-
in fractures involving the dental arch. In cases of sion, if present. Although I have used MMF screws
fractures distal to the dental arch, when there is in the past, my preference is the traditional arch
postoperative malocclusion due to masticator bars with circumdental wiring. I have found diffi-
muscle dysfunction or soft-tissue swelling, I also culty with maintaining stable occlusion with MMF
use elastic interdental fixation to guide the patient screws, and they cannot be used for postoperative
into normal occlusion. Interdental fixation, obvi- elastic interdental fixation if necessary. Moreover,
ously, is also used for subcondylar or condylar frac- arch bars are effective at reducing and stabilizing
tures treated with closed reduction. I do not comminuted fractures involving the alveolar ridge.

DUCIC
Maintaining or reestablishing proper occlusion is 2. Where there is no anticipation of needing post-
one of the most important goals in mandible frac- operative guiding elastics.
ture repair. Multiple methods exist for this purpose.
Intraoperative MMF such as with MMF screws is In situations where there may be a need for post-
a rapid and effective method we use in 2 scenarios: operative guiding elastics such as subcondylar frac-
tures, comminuted fractures, or multiple fractures of
1. Where the patient’s dentition is too poor or the mandible, it would be the unusual patient who
inadequate to accept proper arch bar fixation. would not benefit from traditional MMF with arch
bars. This approach remains the gold standard.
TOLLEFSON
I choose to use MMF for mandible fracture stabili- pediatric cases, ligatures or MMF will be
zation in: removed after ORIF except when addressing
condylar fractures with functional adaptation.
1. Nearly all isolated condyle, ramus, angle, and
body fractures
2. Those patients with 2 or more fracture sites
(Fig. 6).
In patients with adequate dentition I prefer an
open approach for fracture reduction, which
affords intraoperative visualization of the fracture
segments while reproducing the dental occlusion
(based on wear facets and classic definitions).
MMF is maintained to stabilize occlusion during
ORIF. I prefer to leave the arch bars in place and
apply guiding elastics for up to 4 weeks.
There are 3 broad categories in which I will defer
MMF: isolated anterior fractures; pediatric cases;
Fig. 6. Intraoperative photograph of erich arch bars
and when absent, diseased dentition precludes and two miniplates used for fixation of a right
its use. I choose Ernst ligatures in those cases mandibular parasymphyseal fracture. Maxillomandib-
where only one fracture in the anterior mandible ular fixation was used due to a concomitant left
(symphyseal/parasymphyseal fractures) is present, mandibular angle fracture. Guiding elastics were
and then remove them after ORIF. Similarly in used post-operatively.
 Mandible Fractures 355

Although some surgeons support the use of in- intended to allow long-term fixation or guiding
termaxillary fixation (IMF) screws for fixation, I elastic capability. The risk of tooth-bud injury
rarely use this option.30 The screws can become with IMF screw placement makes circumdental
mobile in the maxillary segment and are not wires my preference in pediatric cases.

How do you manage edentulous mandible fractures?

AROSARENA
The edentulous mandible is typically atrophic. I treated edentulous patients with bilateral condylar
usually manage angle and body fractures in the and subcondylar fractures, I have approached
edentulous mandible with a single 2.4-mm locking these through the parotid, with care being taken
reconstruction plate for stability. I treat unilateral to dissect and preserve the facial nerve, and
condylar and subcondylar fractures in the edentu- have rigidly fixed the fractures with 2.0-mm plates
lous mandible conservatively (soft mechanical diet (one at each fracture site).
or liquid diet). In the few instances when I have

DUCIC
This would depend mostly on the patient’s with a large locking screw plate and major bone
mandible height across the fracture line. If the grafting is often required. Subperiosteal versus
height is at least 20 mm, it is treated as for any supraperiosteal plate placement seems not to be
mandible fracture in the nonedentulous patient. If important when the studies are compared in this
the height is between 10 and 19 mm, we will use regard. Controlling underlying medical problems
rigid fixation with iliac or other bone graft packed that are often seen in the elderly edentulous
around the fracture site. If the height is less than patient population is important, as these may
10 mm then a weight-bearing fixation method also affect healing.

TOLLEFSON
I believe that the use of soft diet and conservative dentures with drill holes, or our dentist will fabricate
observation for edentulous mandible fractures a Gunning splint. These cases often receive
should only be used in the frailest patients, who a tracheotomy, obviating the urge to remove the
would not tolerate general anesthesia. Otherwise, MMF in the immediate postoperative period. I
the premorbid jaw position can be estimated by advocate an external approach to complete the
using the patient’s dentures, but these nearly load-bearing ORIF of edentulous mandible frac-
always need to be altered or refabricated after the tures. In cases with 2 fractures, I choose a large
large 2.4-mm mandibular locking plate is applied plate that extends through both fractures with 3 or
to the fracture(s) through an external approach. In more screws on each side of the fracture. In the
a rare case where complex maxillary fractures primary setting, if the fracture segments involve
and an edentulous mandible fracture are present, “pencil-thin” or osteoporotic bone, I prefer the iliac
I will complete MMF by modifying the patient’s crest as the cancellous bone graft harvest site.

Analysis: Over the past 5 years, how has your technique or approach
changed or what is the most important thing you have learned in dealing
with mandible fractures?
AROSARENA
Contemplation on mandibular angle fractures
The method of fixation of mandibular angle frac- with monocortical screws so as not to injure the
tures that I have used and that has resulted in the inferior alveolar nerve (Fig. 7). I believe that this
fewest postoperative complications in terms of approach minimizes the exposure of the bone to
infection is a transcutaneous approach with a non- the contaminated oral cavity, and because a drain
compression, 6-hole miniplate placed along the is placed, the risk of hematoma is minimized.
inferior border and secured with bicortical screws, However, because I have had patients develop
in conjunction with a 4-hole tension band secured hypertrophic scarring and transient facial nerve
356 Arosarena, Ducic, Tollefson

Fig. 7. Orthopantograms of a 46-year-old man with an isolated left mandibular angle fracture. (A) Preoperative
orthopantogram. (B) Postoperative orthopantogram showing fracture fixation with a 7-hole miniplate placed
near the inferior border with a 4-hole tension band. The approach was transcutaneous.

injury with this approach, my current preference is reduces the stability of the mandible in the angle
a biplanar technique with a miniplate placed at region, and I do not believe that a single miniplate
the internal oblique line with monocortical screws, can restore adequate stability for uncomplicated
and a second miniplate placed just below this on bone healing when the third molar has to be ex-
the buccal cortex with bicortical screws using tracted.9,12 I have used the Champy technique in
a transbuccal trocar (Fig. 8). Although this has re- instances when the fracture was minimally dis-
sulted in noticeable scars in a few patients, I believe placed and the third molar did not have to be ex-
that this technique affords enough stability to over- tracted, and I have also used a single miniplate
come distractive and torsional forces, especially if along the buccal cortex (Fig. 9). Like other investi-
the third molar has to be removed because it is gators, I have not noted an increase in complica-
carious, has broken roots, or is impeding fracture tions whether 1 miniplate or 2 miniplates were
reduction. Removal of the third molar significantly used for angle fracture management.7,10,13,14

Contemplation on teeth in the fracture line

Despite the trend in the literature to retain teeth in the population I serve at an inner-city, tertiary care,
line of fracture, I find that the criteria for preserving academic medical center. Moreover, many of my
teeth (strict oral hygiene, radiologic and clinical patients have no access to endodontic therapy
monitoring) often cannot be met in the patient given their uninsured status. Thus, the viability of

Fig. 8. Radiographs of a 19-year-old man with a left mandibular angle and right parasymphyseal mandibular
fractures. (A) Preoperative orthopantogram. (B) Postoperative orthopantogram demonstrating placement of
a miniplate along the oblique line with a second plate placed just below this along the buccal cortex. (C) Lateral
mandibular radiograph taken 2 years after the initial injury, demonstrating healing of the fracture.
 Mandible Fractures 357

Fig. 9. Orthopantograms demonstrating fixation of mandibular angle fractures with a single miniplate. (A) Post-
operative orthopantogram demonstrating fixation of a left mandibular angle fracture with the Champy tech-
nique in a 33-year-old man. (B) Preoperative orthopantogram of a 22-year-old man with left angle and right
body mandibular fractures. (C) Orthopantogram of patient in B taken 1 month after fixation of angle fracture
with a single plate along the buccal cortex.

the tooth is only one consideration in my decisions to of postsurgical infection resulted from my decision
preserve or extract teeth in the line of fracture. In to preserve viable-appearing, stable teeth despite
fact, I believe that a tendency on my part to be too the roots being partially exposed (Figs. 10 and 11).
conservative with tooth extraction has resulted in I am now more aggressive with removal of teeth
some unnecessary complications. At least 2 cases with exposed roots.

Fig. 10. Orthopantograms of a 38-year-old woman with bilateral subcondylar and right parasymphyseal mandib-
ular fractures. (A) Preoperative orthopantogram. (B) Postoperative orthopantogram demonstrating ORIF of frac-
tures. The subcondylar fractures were repaired via transparotid approaches given the patient’s poor dentition.
During repair of the right parasymphyseal fracture, the decision was made to retain the tooth mesial to the frac-
ture because it seemed stable and healthy. (C) Orthopantogram taken 2 weeks after fracture repair when patient
returned with infection at the fracture line. The nonunion healed with removal of the tooth at the fracture line
and conservative treatment with antibiotics.
358 Arosarena, Ducic, Tollefson

Fig. 11. Orthopantograms of a 51-year-old man with bilateral subcondylar and left parasymphyseal mandibular frac-
tures. (A) Immediate postoperative orthopantogram demonstrating good reduction of fractures. The subcondylar frac-
tures were repaired via a transparotid approach. (B) The patient presented with pain and granulation tissue at the site
of the parasymphyseal fracture 2 months after repair, and this orthopantogram demonstrated nonunion of that frac-
ture. (C) Orthopantogram taken 7 months after initial repair. In the interim between this radiograph and that in B, the
patient was taken to the operating room where he was found to have partial union of the lingual cortex of the
mandible at the parasymphyseal fracture site. The decision was made to remove the hardware and do nothing more.

Contemplation on postoperative antibiotics

Orthognathic surgery is analogous to the treat- infections associated with mandible fractures. It
ment of mandible fractures in that osteotomies is impossible for studies to control for all of these
are made within the same contaminated oral cavity factors, which include, but are not limited to: (1)
environment, although the infection rates with or- delay in treatment, (2) periodontal disease, (3)
thognathic surgery are considerably lower than other comorbidities, (4) imperfect social situation,
those with mandible fracture treatment, and most (5) patient noncompliance, and (6) teeth in the
studies have not shown prophylactic antibiotics line of fracture. In my practice, most patients
to be preventive in orthognathic surgery.24 This with facial trauma present with several of the
finding indicates that factors beside the contami- aforementioned factors, so the use of prophylactic
nated field are operative in the pathogenesis of postoperative antibiotics must be individualized.

Delay in treatment It is not unusual to have delay, so that these data were retrospective in
patients present for initial evaluation several weeks nature.25 Fox and Kellman29 also noted that delay
after suffering a mandible fracture. In other in treatment did not statistically increase the
instances, patients with multiple injuries, particu- complication rate in their study, but did not specify
larly those with intracranial hemorrhages, cervical the average delay period in their series. In a study
spine fractures, and other central nervous system where approximately 76% of patients presented
insults, may have definitive treatment of facial frac- after 3 days for treatment of facial fractures, and
tures delayed several days until the patient’s other 36% presented between 3 and 10 days, Abiose30
conditions stabilize. In their study of 101 patients reported a 56% infection rate despite the use of
with facial fractures, Chole and Yee25 did not find perioperative antibiotics. The two cases of osteo-
that delay of treatment affected infection rate, myelitis of the mandible resulting from fractures
with or without the use of perioperative antibiotics. that I treated occurred in patients who presented
However, the average delay of treatment for late for treatment, one of whom presented with an
patients in this study was less than 2 days, and abscess. I routinely provide a 5-day course of post-
the investigators conceded that the protocol was operative antibiotics for patients with a treatment
not designed to study the effects of treatment delay of several days.

Periodontal disease and other comorbidities Peri- infections in the treatment of mandible fractures,
odontal disease predisposes to postoperative and is associated with poor dental hygiene.18 Other
 Mandible Fractures 359

comorbidities such as diabetes, human immuno- with cirrhosis) that may have predisposed to infec-
deficiency virus (HIV) disease, malnutrition, and tion. Again, these results may be skewed by the
substance abuse are also associated with infec- high attrition rate in this study. However, they did
tions, the latter being closely linked to patient demonstrate that infections were more prevalent
noncompliance. In their study, in which patients in patients with combined alcohol and tobacco
were recruited from a population similar to the use.26 Similarly, Lovato and Wagner28 found that
one I serve, Miles and colleagues26 found that the incidence of infection was higher in patients
only 3 of the 22 patients who developed infections with a history of drug use. I prescribe postoperative
after open treatment of mandible fractures had past antibiotics for patients with periodontal disease
medical histories (HIV disease, hepatitis C infection and other comorbidities.

Social situation Compliance with postoperative site. After successful treatment of the infection, the
instructions, including the use of oral rinses, and fracture went on to heal, although the patient did
dental hygiene is often difficult for populations not return for follow-up after his second hospitali-
that are transient, homeless, and indigent. I had zation until a year later because his arch bars were
one homeless patient who was discharged without becoming a nuisance to him. As these are patients
antibiotics return 3 weeks later with a deep neck who also tend to have significant comorbidities, I
infection arising from his parasymphyseal fracture discharge them with a short course of antibiotics.

Teeth in the line of fracture One of the stated line of fracture may not increase these risks in
conditions for maintenance of teeth in the line of patients with good dentition and dental hygiene, I
fracture is antibiotic prophylaxis.18 Before the anti- am inclined to give antibiotic prophylaxis in
biotic era routine extraction of teeth in the line of patients with poor dentition and/or poor dental
fracture was advocated, because of the risks of hygiene for the stated reasons.
osteomyelitis and nonunion. Although teeth in the

DUCIC
Over the past few years I have transitioned to less soon as possible. Also, greater reliance on 2
and less need for MMF. There is a tendency to monocortical miniplates for noncomminuted
a greater use of intraoperative arch bars or MMF body and symphyseal fractures and less reliance
screws with removal at the completion of the on more rigid techniques has been associated
procedure. In addition, very few patients require with increased ease of fixation and favorable post-
MMF postoperatively and most are mobilized as operative outcomes.

TOLLEFSON
As surgeons shift toward a more objective, 3. Approach and fixation in uncomplicated angle
evidence-based analysis of surgical outcomes, fractures
the expert opinion will inherently affect practice 4. Immediate use of guiding elastics
trends to a diminishing degree. The experienced 5. Use of resorbable plates for pediatric cases.
surgeon’s opinion will still be valuable, as experi-
The first 3 listed are thoroughly discussed in the
ential learning is especially important in the less
discussion topics 1 and 2. As surgeons moved
prevalent surgical treatments. However, the
away from inferior border compression plates,
opinion will be shaped by research that draws
the use of adaptive osteosynthesis has gained
from evidence-based medicine, emphasizing
attention. My experience in using one miniplate
systematic reviews and prospective cohort
on the oblique line in angle fractures is consistent
studies over case reports and small retrospective
with the other reports that support the theory of
reviews.31,32 This process, similar to Epstein’s
lines of osteosynthesis.34–36 If an angle fracture
description of observational analysis, will be “es-
has significant comminution, then traditional
tablished by comparisons, by shifting shades of
plating through an external approach is my prefer-
difference, turned over and teased out”.33
ence. Five years ago, I used a transoral/transbuc-
My practice habits in mandible fracture
cal approach to place 2 plates on the lateral
management have changed in, at least, the
surface of angle with bicortical screws in the infe-
following trends:
rior border.
1. Increased use of functionally stable fixation37 From exposure to oral surgery colleagues in the
2. Use of an envelope vestibular incision for angle AO-ASIF, I began using an envelope vestibular
fractures when the third molar is extracted incision for transoral angle fracture repair in cases
360 Arosarena, Ducic, Tollefson

that necessitated the removal of a loose or de- systems to have both benefits and limitations.
cayed third molar in the fracture line. Using this The absorbable plates certainly preclude the
incision, the gingiva is lifted directly from the need for reoperation to remove titanium hardware
molars and then extends posteriorly in the stan- in a growing mandible. However, if MMF is still
dard vestibular incision. This approach has the used then the child needs a second anesthesia
benefit of affording mucosal closure over the to remove the arch bars as well. Rigid fixation for
socket. In general, I attempt to limit periosteal pediatric cases ideally will be strong enough to
dissection in uncomplicated fractures and will obviate postoperative MMF, while absorbing
use 2 monocortical miniplates in nondisplaced, rapidly enough to limit the time-limited edema
parasymphyseal fractures, instead of a larger infe- from the implant.
rior border, bicortical application. Mandible fracture management trends have
I still prefer Erich arch bar application over 4- shifted from immobilization, to wire osteosynthe-
screw MMF screw systems, but have shifted sis, to ORIF with large, load-bearing plates.
away from wire fixation at the end of surgery. Current recommendations for some fractures
Guiding elastics are used immediately postopera- support periosteal dissection, less plating, and
tively and continued for 2 to 6 weeks depending on early return to function. Discussions and collabo-
the patient’s malocclusion potential. This practice rative studies between surgeons will help guide
theoretically promotes bone growth by applying us to drive innovative practices at a pace that
an early load to the mandible during healing.37 allows evolution, but with cautious investigation,
Lastly, in a limited number of pediatric mandible as the bar continues to be set higher within facial
cases, I have found the absorbable plating fracture management.

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362 Arosarena, Ducic, Tollefson

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REFERENCE: TOLLEFSON: MMF

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 Mandible Fractures 363

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