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EDWARD ELLIS III. A STUDY OF 2 BONE PLATING METHODS FOR FRACTURES OF MANDIBULAR SYMPHYSIS /BODY. J ORAL MAXILLOFAC SURG 69:1978-1987, 2011.
PRESENTED BY – DR. SHEETAL KAPSE
GUIDED BY – DR. RAJASEKHAR G.
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AUTHOR
Professor and Chair, Department of Oral and
Maxillofacial Surgery, University of Texas
Health Science Center, San Antonio, TX.
EDWARD ELLIS III
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CONTENTS
• Introduction• Aim of the study• Patients and methods• Surgical technique• Results • Discussion• Cross references• Conclusion• References
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INTRODUCTION• Fractures of the symphysis and body of the mandible are
extremely common injuries.
• When open reduction and internal fixation is chosen as treatment, many internal fixation schemes can be employed.
• Perhaps the most common is the application of 2 small (mini-) plates or 1 larger plate, with or without an arch bar.
• Based on surgeon preference, experience, availability of internal fixation hardware, or other factors rather than documented outcome measurements.
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Aim of the study
• To evaluate outcomes in patients treated by 1 of these 2
internal fixation schemes for fractures of the mandibular
symphysis or body.
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PATIENTS AND METHODS
• All patients treated by open reduction and internal fixation of a symphysis and/or
body fracture of the mandible from January 1, 1998, through December
31,2009, at Parkland Hospital, Dallas, Texas.
Inclusion criteria 1. intraoral surgical approach2. simple (linear, noncomminuted) fracture 3. 2 miniplates secured with locking or nonlocking 2.0-mm monocortical screws or 1
larger/thicker plate secured with bicortical 2.0-mm locking screws across the fracture4. teeth present in area of fracture5. arch bar placed during surgery and maintained postoperatively for at least 5 weeks6. no postoperative intermaxillary fixation7. minimum follow-up of 5 -7 weeks8. sufficient documentation to be included (medical records, radiographs, photographs)
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Evaluation parameters
1. Infection (diagnosed clinically, not with cultures)
2. Dehiscence of the incision not related to infection (no
purulence)
3. Duration between surgery and dehiscence of incision
and/or infection
4. Exposure of bone plate(s)
5. Need for plate removal
6. Damage to tooth roots
7. Malocclusion attributable to symphysis/ body fracture
8. Clinical union at last visit
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Surgical techniqueTwo methods of internal fixation
C, Intraoperative photograph showing application of 1 larger, stronger plate.
A, Photograph showing relative thickness of the 2 plates. Miniplate (left) is 1 mm thick and the other plate (right) is 1.25 mm thick.
B, Intraoperative photograph showing the application of 2 miniplates.
The additional thickness of the larger plate combined with an increase in the width of the plate confers more than 3 as much volume of metal in the plate, giving it more than 2 the in-plane bending strength and 2.5 out-of-plane bending strength compared with the miniplate.
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Results
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Discussion
• The application of an arch bar and 2 miniplates or 1 larger, stronger bone plate can be considered “rigid” fixation, meaning that the fixation is stable enough. Any differences in outcomes between the 2 groups in this study would unlikely be due to differences in stability imparted to the fracture.
• Application of a second plate higher on the lateral surface of the mandible can result in more complications than when 1 stronger plate is applied to the lateral cortex along the inferior border.
• Cawood JI: Small plate osteosynthesis of mandibular fractures. Br J Oral Maxillofac Surg 23:77, 1985
• Nakamura S, Takenoshita Y, Oka M: Complications of miniplate osteosynthesis for mandibular fractures. J Oral Maxillofac Surg 52:233, 1994
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• Dehiscence in this sample occurred with a much higher frequency in those cases in which 2 miniplates were used (6%), and it was most commonly associated with exposure of the plate located just below the incision (5%).
• Tooth root injuries in the present sample occurred exclusively in the 2-plate group, albeit at a very low incidence (n = 4/265, 1.5%).
• In the premolar to premolar dentoalveolar areas, one will see that the facial plate of bone is very thin (2.0 – 2.5 mm) and the roots are immediately within.
• Cawood JI: Small plate osteosynthesis of mandibular fractures. Br J Oral Maxillofac Surg 23:77, 1985
• Nakamura S, Takenoshita Y, Oka M: Complications of miniplate osteosynthesis for mandibular fractures. J Oral Maxillofac Surg 52:233, 1994
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Cross references
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• In front of the mandibular foramen, or, accurately, in front of
the canine, 2 malleable plates, 4.5 mm apart, are required to
prevent torsion moments.
• The inferior plate is inserted first, then the sub-apical one.
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• The aim of this study was to make a comparative evaluation of the mechanical behaviour of 4 different internal fixation systems for mandibular symphysis fractures.
• 40 polyurethane mandible replicas (Nacional, Jaú, SP, Brazil) were used. The load resistance values were measured at load application displacements of 1, 3, 5, and 10 mm.
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Fixation of group with lag
screw technique, with A, frontal
and B, side views.
Fixation of group with 2 perpendicular
miniplates, withA, frontal and B, inferior-superior
views.
Fixation of group with 1 miniplate in the tensionzone. Fracture reduction
was achieved with relief of the acrylic devices.
Fixation of group with 2 parallel miniplates, 1 in the tension zone and the other in the compression zone.
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Distortion of the mandible during unilateral molar loading. The distortion of the mandibular body can be described as a combination of sagittal bending, torsion and lateral transverse bending. Patterns of stress and deformation at the mandibular symphysis. Jaw deformation during function. MC, medial convergence; CR, corporal rotation; DVS, dorso-ventral shear.
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Conclusion
• The 2 plating techniques used in the present study show very
good outcomes, but the application of a second bone plate
increased the incidence of wound dehiscence, plate exposure,
and need for plate removal.
• The use of 2 miniplates was associated with more post-
operative complications than the use of 1 stronger plate, but
both techniques produced sufficient stability for healing.
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References
1. Cawood JI: Small plate osteosynthesis of mandibular fractures. Br J Oral Maxillofac Surg 23:77, 1985
2. Nakamura S, Takenoshita Y, Oka M: Complications of miniplate osteosynthesis for mandibular fractures. J Oral Maxillofac Surg 52:233, 1994
3. Champy M et al. Mandibular osteosyntesis by miniature screwed plates via a buccal approach. J Max-Fac Surg. 1978;6:14-21
4. R. C. W. Wong, H. Tideman, L. Kin, M. A. W. Merkx: Biomechanics of mandibular reconstruction: a review. Int. J. Oral Maxillofac. Surg. 2010; 39: 313–319.