http://dx.doi.org/10.5125/jkaoms.2014.40.6.

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ORIGINAL ARTICLE pISSN 2234-7550·eISSN 2234-5930

Reconstruction plates used in the surgery for mandibular discontinuity defect

Guk-Jin Seol, Eun-Gyu Jeon, Jong-Sung Lee, So-Young Choi, Jin-Wook Kim, Tae-Geon Kwon, Jun-Young Paeng
Department of Oral and Maxillofacial Surgery, Kyungpook National University School of Dentistry, Daegu, Korea

Abstract (J Korean Assoc Oral Maxillofac Surg 2014;40:266-271)

Objectives: The purpose of this study was to analyze the survival rate of reconstruction plates that were used to correct mandibular discontinuity de-
fects.
Materials and Methods: We analyzed clinical and radiological data of 36 patients. Only discontinuous mandibular defect cases were included in
the study. Reconstruction plate survival rate was analyzed according to age, gender, location of defect, defect size, and whether the patient underwent a
bone graft procedure, coronoidectomy, and/or postoperative radiation therapy (RT).
Results: Plate-related complications developed in 8 patients, 7 of which underwent plate removal. No significant differences were found in plate sur-
vival rate according to age, gender, location of defect, defect size, or whether a bone graft procedure was performed. However, there were differences
in the plate survival rate that depended on whether the patient underwent coronoidectomy or postoperative RT. In the early stages (9.25±5.10 months),
plate fracture was the most common complication, but in the later stages (35.75±17.00 months), screw loosening was the most common complication.
Conclusion: It is important to establish the time-related risk of complications such as plate fracture or screw loosening. Coronoidectomy should be
considered in most cases to prevent complications. Postoperative RT can affect the survival rate and hazard rate after a reconstruction plate is fitted.

Key words: Mandibular reconstruciton, Complications, Survival rates

[paper submitted 2014. 8. 12 / revised 2014. 9. 16 / accepted 2014. 9. 29]

I. Introduction The first generation of clinically available reconstruction

plates was introduced in the mid-1970s2. Since the early
Surgical treatment for malignant tumors, benign tumors, 1980s, the standard treatment for a mandibular discontinuity
trauma, or jaw necrosis often requires subsequent treatment defect has been the use of a rigid reconstruction plate with
to recover functionality and correct aesthetic problems. Man- concurrent or subsequent osseous reconstruction3. Recently,
dibular reconstruction plates are used in oral and maxillofa- the effectiveness of osteosynthesis has improved with the
cial surgery for mandibular defect reconstruction. Because use of titanium reconstruction plates, which provide better
the mandible plays a central role in function and aesthetics, biocompatibility, and locking screws for biomechanical im-
the loss of jaw continuity can severely impair a patient’s jaw provement. With these improvements, modern reconstruction
integrity, and severely affect the patient’s self-perception and plates can provide excellent anchorage and rigid fixation4,5.
self-confidence1. However, postoperative plate-related complications (Fig. 1),
The main goals of mandibular reconstruction are to restore including plate exposure, plate fracture, screw loosening, and
the continuity of the mandible arch and provide support to the infection still occur occasionally6,7.
outer soft tissue, which in turn can support functional and aes- Therefore, this study aimed to evaluate the factors associat-
thetic rehabilitation and improved postoperative quality of life. ed with postoperative complications and analyze the survival
rate of the mandibular reconstruction plate.
Jun-Young Paeng
Department of Oral and Maxillofacial Surgery, Kyungpook National University
School of Dentistry, 2175 Dalgubeol-daero, Jung-gu, Daegu 700-705, Korea II. Materials and Methods
TEL: +82-53-600-7551 FAX: +82-53-426-5365
E-mail: [email protected]
In this study, 36 patients (20 male and 16 female) who had
CC This is an open-access article distributed under the terms of the Creative Commons
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), discontinuity defects were included among a total of 77 pa-
which permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited. tients who underwent reconstruction plate procedures. Only
Copyright 2014 The Korean Association of Oral and Maxillofacial Surgeons. All cases of discontinuous mandibular defect were included in
rights reserved.

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 Reconstruction plates used in the surgery for mandibular discontinuity defect

Fig. 1. Plate-related complications: plate exposure, plate fracture, and screw loosening.
Guk-Jin Seol et al: Reconstruction plates used in the surgery for mandibular discontinuity defect. J Korean Assoc Oral Maxillofac Surg 2014

the study; the other 41 patients with mandibular continuity Table 1. Disease processes underlying mandibular discontinuity
defect cases
defects were excluded. The patients visited the Kyungpook
Pathological diagnosis Cases (n) Frequency (%)
National University Department of Oral and Maxillofacial
Malignant tumor 15 41.7
Surgery between 2004 and 2013. They underwent a surgical Benign tumor 12 33.4
operation and reconstruction plates were used to correct the Fracture 7 19.4
Osteomyelitis 2 5.6
mandibular discontinuity defect and to reconstruct the defect.
Guk-Jin Seol et al: Reconstruction plates used in the surgery for mandibular discontinuity
The surgical procedures were performed while the patients defect. J Korean Assoc Oral Maxillofac Surg 2014
were under general anesthesia. The clinical history, radio-
logical data, and survival rate of the reconstruction plates
were analyzed according to age, gender, location of defect, Kyungpook National University Hospital (No. 2014-07-016).
removal of the coronoid process, use of bone graft in the
reconstruction, and whether postoperative radiation therapy III. Results
(RT) was performed. Synthes Reconstruction Plates (Syn-
thes, Westchester, PA, USA) or Jeil Medical Maxi Plates 2.4 The mean age of the patients was 45.7±17.0 years and the
(Jeil Medical, Seoul, Korea) were used as the reconstruction mean follow-up period was 23.9±20.0 months (median 19
plates. Twenty-seven Synthes Reconstruction Plates and months) and ranged from 1 week to 7 years and 6 months. The
nine Jeil medical Maxi Plates were used for the mandibular patients had a number of different diagnoses, including malig-
reconstruction. The survival rate of the reconstruction plate nant tumor presence, benign tumor, severe mandibular frac-
according to gender, whether a bone graft procedure and/or ture, and large cystic lesions. Malignant tumors accounted for
coronoidectomy were performed, the overall survival rate, 15 cases (41.7%), benign tumors for 12 cases (33.4%), frac-
and the hazard rate were analyzed for statistical significance tures for 7 cases (19.4%), and osteomyelitis for 2 cases (5.6%).
by Fisher’s exact test and Pearson’s chi-squared test, and (Table 1) The overall postoperative plate-related complications
confirmed with a log-rank test. All tests were performed and affecting factors are summarized in Table 2. Postoperative
with the R (R Development Core Team, 2013; http://www. plate-related complications occurred in 8 (4 plate fracture and
r-project.org) software package on a personal computer, and 4 screw loosening cases) of 36 patients (22.2%); of these 8,
P <0.05 was accepted as the level of statistical significance. 7 patients (87.5% of patients with complications) underwent
This study was approved by the institutional review board of plate removal. One patient experienced a screw loosening

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Table 2. Overall postoperative plate-related complications

Assessment
Variable
1 2 3 4 5 6 7 8
Age (yr) 42 70 57 23 40 69 48 48
Gender Male Male Male Male Female Male Female Male
Diagnosis MT MT MT BT BT MT MT BT
LOD Right angle Right angle Left angle Left angle Right body Left angle Right angle Right angle
Bone graft � × � � � × × ×
Plate type Synthes1 Synthes1 Synthes1 Jeil2 Jeil2 Jeil2 Synthes1 Synthes1
Coronoidectomy × × × × × × × ×
Postoperative RT � � × × × × � ×
Complications Loosen Fracture Loosen Fracture Loosen Loosen Fracture Fracture
Plate removal � � × � � � � �
F/U duration (m) 36 14 14 71 54 40 10 2
(MT: malignant tumor, BT: benign tumor, LOD: location of defect, RT: radiation therapy, F/U: follow-up)
1
Synthes Reconstruction Plates, 2Jeil Medical Maxi Plates.
Guk-Jin Seol et al: Reconstruction plates used in the surgery for mandibular discontinuity defect. J Korean Assoc Oral Maxillofac Surg 2014

A B
1.0 1.0
Survival rate of reconstruction plate

Survival rate of reconstruction plate

Female (n=16) Without bone graft (n=20)
0.8 0.8

0.6 Male (n=20) 0.6 With bone graft (n=16)

0.4 0.4

0.2 0.2
Log-rank test, P=0.242 Log-rank test, P=0.246
0.0 0.0
0 10 20 30 40 50 60 0 10 20 30 40 50 60
Time (mo) Time (mo)

Fig. 2. A. No significant difference was found for the reconstruction plate survival rate between males and females. B. No significant differ-
ence was found for the reconstruction plate survival rate between patients that did or did not receive a bone graft.
Guk-Jin Seol et al: Reconstruction plates used in the surgery for mandibular discontinuity defect. J Korean Assoc Oral Maxillofac Surg 2014

complication but refused the removal surgery. 1.0

Survival rate of reconstruction plate

Coronoid (n=9)
There was no relationship between the survival rate of the
0.8
reconstruction plate and the gender of the patient or the loca-
tion of the defect.(Fig. 2. A) Plate fracture occurred in 4.8% 0.6
of the patients (n=1) who received a bone graft and in 20% Coronoid + (n=27)

of patients (n=3) who did not receive a bone graft. However, 0.4
the difference between the two groups was not statistically
significant (log-rank test, P =0.246).(Fig. 2. B) 0.2

The survival rate of the reconstruction plate was significantly Log-rank test, P=0.032
0.0
higher in patients who underwent coronoidectomy than in
0 10 20 30 40 50 60
those who did not (log-rank test, P =0.032).(Fig. 3) None of the
Time (mo)
9 patients that underwent mandibular reconstructive surgery
Fig. 3. A significant difference was found between patients who
with coronoidectomy showed any complications; in contrast, received a coronoidectomy and those that did not.
7 out of 27 patients (25.9%) that did not undergo coronoidec- Guk-Jin Seol et al: Reconstruction plates used in the surgery for mandibular discontinuity
defect. J Korean Assoc Oral Maxillofac Surg 2014
tomy had their reconstruction plates removed.(Fig. 4)
The main reasons for plate removal were fracture or recon-

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 Reconstruction plates used in the surgery for mandibular discontinuity defect

1.0

Survival rate of reconstruction plate

RT (n=28)
0.8

0.6

RT (n=8)
0.4

0.2
Log-rank test, P=0.012
0.0
0 10 20 30 40 50 60
Time (mo)

Fig. 7. Survival curves showing the decreased survival rate of re-

construction plates following postoperative radiation therapy (RT).
Guk-Jin Seol et al: Reconstruction plates used in the surgery for mandibular discontinuity
defect. J Korean Assoc Oral Maxillofac Surg 2014

Fig. 4. In two similar cases, reconstruction plate fracture did not oc-
cur in the patient who underwent coronoidectomy, while plate frac-
ture occurred in the patient who did not undergo coronoidectomy.
Guk-Jin Seol et al: Reconstruction plates used in the surgery for mandibular discontinuity
defect. J Korean Assoc Oral Maxillofac Surg 2014

1.0 0.04
Survival rate of reconstruction plate

0.8

n=36
Hazard rate

0.6
0.02
0.4

0.2

0.0 0.00
0 10 20 30 40 50 60 0 10 20 30 40 50 60
Time (mo) Follow-up time (mo)

Fig. 5. The overall survival rate, the survival curve over the first 10 months and after 35 months. A similar trend was apparent for the hazard
rate, the risk of complications was low from the 10 to 35 months. Red box: high risk of plate fracture. Blue box: high risk of screw loosening.
Guk-Jin Seol et al: Reconstruction plates used in the surgery for mandibular discontinuity defect. J Korean Assoc Oral Maxillofac Surg 2014

Fig. 6. Schematic images representing cases in which complications developed. A defect of the mandibular angle present in almost all cases.
Guk-Jin Seol et al: Reconstruction plates used in the surgery for mandibular discontinuity defect. J Korean Assoc Oral Maxillofac Surg 2014

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J Korean Assoc Oral Maxillofac Surg 2014;40:266-271

struction plate screw loosening. Analysis of the hazard rates stress on the reconstruction plate may be reduced, resulting
and overall survival rates (Fig. 5) indicated that plate fracture in a decrease in plate-related complications. In this study, no
was the main cause of complications in the early stages follow- mechanical complications were observed for any cases where
ing surgery (9.25±5.10 months), but screw loosening was the the coronoid process had been removed.
main complication in the later stages (35.75±17.00 months). Postoperative RT can be an important factor in plate-relat-
Most complications associated with the reconstruction ed complications and these are biological in origin. Previous
plate developed in patients with a discontinuous defect in authors have reported a decreased success rate following
the mandibular angle area.(Fig. 6) These patients also had an RT1,15,16. Other studies have reported that there is no relation-
anterior or contralateral dentulous condition. There was a sta- ship between success rate and RT17, which differs from the
tistically significant decrease in the survival rate of the recon- results of this study. Meanwhile, Maurer et al.1 reported that
struction plates in patients who had received postoperative the first one-year success rate decreased according to the RT
RT (log-rank test, P =0.012).(Fig. 7) The irradiated patients from 64% to 45%, but this finding was not statistically sig-
had a higher risk of plate-related complications. Of a total of nificant (P =0.67). The complications that occurred, according
8 patients that received postoperative RT, 3 patients (37.5%) to RT, were infection, screw loosening and plate fracture.
experienced plate failures. RT damages small vessels, thus reducing the smooth mus-
cle density and progressively thickens the sub-endothelial
IV. Discussion components of the vessel wall and leads to progressive oc-
clusion and fibrosis of the vessels18,19. Marx20 has reported on
The main goals of mandibular reconstruction are to achieve the pathogenesis of jaw osteoradionecrosis which is charac-
functional and esthetic recovery by restoring mandibular arch terized by a reduction of the number of vessels in the fibrotic
continuity, to maintain soft tissue coverage, and to improve periosteum, a reduction in the number of osteoblasts and
the patient’s postoperative quality of life. The success rate osteocytes, and fibrosis of the marrow spaces. The resultant
of mandibular reconstruction has increased as a result of ad- tissue hypovascularity and hypocellularity was exhibited hy-
vances in plate design and materials. However, plate-related poxic damage compared to non-irradiated tissue. A similar
complications still develop frequently and can sometimes mechanism may be the cause of plate-related complications.
cause serious problems for patients. In this study, the patient with RT experienced more mechani-
The plate fractures in this study occurred at approximately cal complications of reconstruction plate, therefore additional
10 months following surgery. Other studies have reported that study with a larger number of samples is needed.
most plate fatigue fractures occur within the first 6 months The effectiveness of bone grafts with the reconstruction
following surgery8-10. Currently, no studies have assessed plate in surgery to correct mandibular discontinuous defects
coronoidectomy influence on the mandibular reconstruction remains controversial. Some authors have reported that there
plate. However, some studies have examined the mechani- is no statistical significance21, while others have found that
cal forces that affect the plate. Kimura et al.11 found that the incidence of plate fracture was higher in patients that did
masticatory pressure can contribute to vertical stress on the not receive bone grafts22,23. In this study, there was a tendency
plate, leading to bone resorption around the screw and screw towards a reduced risk of plate fracture in the patients who
loosening. Arias-Gallo et al.12 reported that most hardware had received bone grafts (1 fracture out of 4 grafted cases),
complications developed at sites exposed to higher moment but this result was not statistically significant. There were no
and shear forces. Mandibular functional movements such significant differences in plate survival rate according to age,
as mastication cause mechanical stress, an important factor gender, or defect size. These results were similar to conclu-
in complications. Forces that are caused by contracture of sions of previous reports1,17.
the masticatory muscles (temporalis muscle, lateral and me- Based on the results of this study, coronoidectomy is helpful
dial pterygoid muscle, masseter muscle) during mastication for improving the plate survival rate in mandibular discontinu-
act directly on the mandible13. The mandibular temporalis ity defects, especially if the defect included the mandibular
muscles are very powerful14 and are attached to the coronoid angle area. During the postoperative follow up period, it is bet-
process of the mandible. As a consequence, when the surgi- ter to carefully observe the complications such as plate fracture
cal procedure includes a coronoidectomy, the force of the or screw loosening over time. Postoperative RT could increase
temporalis muscle is not delivered to the mandible, and so the the risk of reconstruction plate complications as well as other

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complications such as dysphagia and trismus. Therefore, it is fractured mandibular reconstruction plates. J Oral Maxillofac Surg
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Conflict of Interest Case report removal of exposed titanium reconstruction plate after
mandibular reconstruction with a free fibula osteocutaneous flap
No potential conflict of interest relevant to this article was with large surgical pin cutters: a case report and literature review.
Eplasty 2012;12:e42.
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