AIM: The aim of this follow-up study was to evaluate the efficacy of 3- dimensional titanium miniplates in

the treatment of mandibular fractures.

Materials and methods: A prospective randomized clinical trial was carried out in patients with well-defined

inclusion and exclusion criteria. Patients were followed for minimum of 3 months and maximum of 11

months for few patients for post-operative occlusion, infection, segmental mobility, radiological evaluation of

reduction and fixation. The advantages and disadvantages of 3- dimensional plates were also studied.

RESULTS: Seventeen patients were enrolled in the study. 26 surgical sites were treated using three

dimensional titanium miniplates. Clinical and radiographic evaluation indicated union of all fractures at three

months follow up with adequate function. Infection was reported in 2 patients (11.76 %) with restricted mouth

opening in one case (5.9%).

Conclusion: Three-dimensional titanium miniplate provides good stability, is cost- effective, requires less

operative time and a safe alternative to conventional miniplates. However, it is unsuitable for fractures

involving the mental foramen and limits the operator in adjusting the horizontal bar distance, if required, as

determined by the fracture pattern in order to maintain the integrity of associated vital structures.

1 2 3Munish Kumar, Ravi Narula, Bhavna Malik Gothi 1Professor and Head, Department of Oral and Maxillofacial Surgery,Guru Nanak Dev Dental College and Research Institute, Sunam.2Professor, Department of Oral and Maxillofacial Surgery, Guru Nanak Dev Dental College and Research Institute, Sunam.3Senior Resident, Department of Dentistry, Shri Guru Ram Rai Institute of Medical & Health Sciences and Shri Mahant Indresh Hospital, Dehradun

INTRODUCTION : Mandibular fractures are common facial injuries, and their treatment is one of the most frequent forms of therapy provided by oral and maxillofacial service8. The variability in the pattern of fractures results from the different causes of injury such as road traffic accidents (RTA), assault, falls and sports injuries.

Proper initial assessment and management of such injuries meets the ultimate goals of functional and aesthetic recovery. The treatment of mandibular fractures with return of premorbid function requires the accurate restoration of anatomical form at both the occlusal and skeletal levels. The treatment modalities involve both closed and open reduction, followed by fixation and immobilization. But, conservative management fails to produce rigid fixation and hence bony union is by secondary

intention. Thus, this traditional MMF alone, to provide indirect stabilization of the fractured jaws has been replaced with open reduction & internal fixation with various osteosynthesis systems like AO system, miniplate system, resorbable plates and screws, followed by the most recent rigid fixation, the 3-dimensional titanium miniplates by Mustafa Farmand and Dupoirieux (1992). Nowadays, miniplate fixation of mandibular fractures has become a standard.

The basic concept of three dimensional fixation is that a geometrically closed quadrangular plate secured with bone screws creates stability in three dimensions since it offers good resistance against torque forces. The plates are adapted to the bone according to Champy's priniciples and are secured with monocortical self-cutting screws.

3 DIMENSIONAL TITANIUM MINI PLATE FIXATION IN THE MANAGEMENT OF MANDIBULAR FRACTURES- A PROSPECTIVE STUDY

Keywords :Rigid internal fixation,Miniplates3-D plates

Source of support : NilConflict of interest: None

Journal of Dental Sciences

University

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Clinical Paperand

ComparativeStudies

The present study is aimed at evaluating clinical efficacy of 3-D titanium miniplates in terms of status of occlusion and the restoration of function, to ascertain radiologically the bone healing and to observe any postoperative complication(s).

PATIENTS AND METHODS : After obtaining ethics and research committee approval, a prospective randomized clinical trial was carried out between a period of May 2008 to November 2010 in the Department of Oral and Maxillofacial surgery, Guru Nanak Dev Dental College & Research Institute, Sunam. Informed consent was obtained and patients of both genders within the age group of 17-70 years with isolated mandibular fracture involving symphysis, parasymphysis, or body and angle fractures were included. Preoperative infected or medically compromised patients were excluded. A standardized data sheet was formulated, and demographic variables and relevant clinical and radiographic findings were noted. All patients were given prophylactic antibiotic Cefotaxime 1g intravenously o.5 hour before the procedure followed by 1g BD for 7 days. Upper and lower Ehrich arch bars or eyelets were fixed as indicated to achieve the premorbid occlusion using maxillomandibular fixation. General anesthesia was used in 10 patients and local anesthesia with premedication in rest seven patients. Extra oral approach was used in those cases where fracture fragments were grossly displaced, pre-existing laceration and in patients where reduction was not possible by intra oral approach. Fixation was done with three dimensional miniplates by using one 4 holed or 6 holed three dimensional miniplate and monocortical self tapping screws. The plate was placed in such a way that the horizontal crossbars were perpendicular and the vertical crossbars were parallel to the fracture (Cases 1,2). A water tight wound closure was done. Intermaxillary fixation was released post-operatively. Duration of the procedure was noted. Patients were followed for a period of 3 months at the interval of one week, 2 weeks, 4 weeks, 6 weeks, 8 weeks and 3 months by a blinded senior oral surgeon for postoperative occlusion, restoration of function, inter-incisal opening, segmental mobility and significant postoperative complications and radiological evaluation of reduction and fixation.

RESULTS: Seventeen patients with mandibular fractures were included and 26 fracture sites were treated by open reduction and rigid internal fixation with the help of 2.0mm three dimensional titanium miniplates. Male: female ratio was 16:1. (Table1).

The mechanism of injury and fracture sites are summarized inTable2 and Table 3 respectively. Most of the patients were dentate (70.6%), 4 patients were partially dentate (23.6%) and one was edentulous (5.9%). The average length of time from trauma to repair was 4.26 days. Six patients (35.29%) of the study reported within first week of the injury. Mandibular angle was the commonest fractured site (50%) followed by parasymphysis (46.15%) and body of mandible (3.85%). The

plate contouring and adaptation followed by fixation time was noted down using a stop watch and the average time was found to be 8.50 minutes. Post operative complications reported were wound infection in 2 patients (11.76%), and restricted mouth opening in one patient(5.9%). The infection was treated by draining the pus, wound debridement, antibiotics for five days and placing intermaxillary fixation for 2 weeks without the need of plate removal.

The patient with trismus was relieved after surgical extraction of the impacted 48 after 3 months of adequate fracture healing. All cases showed adequate radiological reduction and fixation. No case of plate fracture was reported during follow up period.

DISCUSSION: General acceptance of osteosynthesis by means of open reduction and internal fixation did not appear in maxillofacial literature until an organized research of AO group in 1950s3. Even in this type of osteosynthesis, there has been a metamorphosis and change in trend from rigid fixation in 1968 to semirigid fixation in 197313. The use of 3D miniplates has not yet become established. In a recently published survey of 104 North American and European AO/ASIF surgeons , only 6% stated that they use this type of plate10. Moreover only a few follow up series are presented in the literature, with few studies emphasizing the hardware related advantages over conventional miniplates and reconstruction plates. These advantages include easy application, simplified adaptation to the bone without distortion or displacement of the fracture, improved biomechanical stability, simultaneous stabilization at superior and inferior borders, and hence less operative time16. Three dimensional titanium miniplates exhibit excellent biocompatibility as experienced by Julio Acero, Javier Calderon et al. Similarly, our study is in agreement with these authors.

Wittenberg in a prospective study, reported the stabilization of 20 fractures of the mandibular angle; 12 were associated with additional fracture of the body using 3D plates. All patients had a stable occlusion after healing of fractures. In 5 cases, in addition to osteosynthesis, light maxillomandibular elastic bands were placed for 2-3 days. In 2 cases, infection occurred because of screw loosening. Infection rates in the clinical studies on 3D plates for angle fractures are 5.4% and 9 %. In this study, most sites of mandibular fractures were treated with 3d plates. Two (10%) cases of infection were noted due to mild segmental mobility and 2 cases involved roots of teeth. Farmand and Dupoirieux also treated 95 fractures of the mandibular body using 4-holed square plates; among the complications, only one late infection and one plate fracture were recorded6. Two cases of infection but no plate fracture occurred in this study. Plate fracture was again a most important complication in the study by Zix et al, in which reduced inter-fragmentary cross-sectional bone surface at the fracture site was cited as the most likely reason5,16. No such scenario was seen in our study.

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According to our study, disadvantages of the 3D system was its unsuitability for fractures involving the mental foramen and the inability to alter the horizontal bar distance, if required, in order to maintain adequate distance from the vital structures. To the best of our knowledge, this has not been mentioned in the literature.

It has been argued that though the implant cost for three dimensional osteosynthesis is slightly higher than the two dimensional systems, but as lesser number of screws are required; it becomes cost-effective in the long term which adds to its numerous advantages10.

It can thus be safely concluded that the 3D titanium miniplate is a cost effective, safe and easy-to-use alternative to conventional miniplates in the management of mandibular fractures with least functional disability and morbidity. A similar study with larger sample size would give more definitive results.

TABLE 1: SEX WISE DISTRIBUTION

TABLE 2: VARIABLE ETIOLOGIES

TABLE 3: SITE OF FRACTURE INVOLVEMENT

(i) Pre-operative (ii) Post-operative Lateral angle Case 1. Bifracture of mandible

(iii) Post-operative Radiograph

Case No.2 Fracture Right Angle of mandible Pre-operative X-ray

Post-operative X-ray

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13. Sankar Anand S., Thangavelu A. Role of indigenous 3-Dimensional Titanium Plating system in Oral and maxillofacial Surgery. J of Maxillofac Oral Surg, 2004; 3: 24-27.

14. Tams J. et al. A three-dimensional study of loads across the fracture for different fracture sites of the mandible. British J of Oral and Maxillofacial Surgery, 1996; 34: 400-405.

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CORRESPONDING AUTHOR: Dr. Munish Kumar127, Green Field, Ludhiana(Punjab)E mail: dr.munishkumar@yahoo.in

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