infection rate in mandibular angle fractures treated with a 2.0-mm 8-hole curved strut plate

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Oral Maxillofac Surg7:804-808, 2009

Infection Rate in Mandibular AngleFractures Treated With a 2.0-mm 8-Hole

Curved Strut PlatePeter Bui, DDS, MD,* Nagi Demian, DDS, MD,† and

Patrick Beetar, BS‡

Purpose: The aim of this study was to determine the rate of postoperative infection and the efficacyof removing teeth in the line of mandibular angle fractures treated with 2.0-mm 8-hole titanium curvedstrut plates. Our understanding is that this method of repair is currently being used only in a few centersin the United States.

Materials and Methods: A retrospective review of mandibular angle fractures treated with a2.0-mm 8-hole strut plate during a 4-year period. Postoperative antibiotics were given for 1 week.Follow-up appointments were 4 weeks or longer. A nonchewing diet was instructed for 6 weeks.Data for all selected patients include the information such as age, gender, etiology of injuries,medical history, concurrent injuries, nerve deficits, pre- and postoperative antibiotic administration,postop infection, a presence or absence of teeth in the line of fractures, and whether these teethwere removed.

Results: Four patients (4 of 49 or 8.2%) developed infections. Two of those patients had a tooth in theline of a fracture that was retained (2 of 14 or 14%). The third had a tooth in the line of a fracture thatwas extracted (1 of 18 or 5.6%). The fourth patient was 1 of the 17 patients who did not have teeth inthe line of fracture and developed infection (1 of 17 or 5.9%). None of the patients developed failedhardware, malunion, nonunion, malocclusion, or iatrogenic nerve injury.

Conclusions: The use of a 2.0-mm 8-hole strut plate is associated with a low infection rate (8.2%). Theinfection rate for those mandibular angle fractures with teeth in the line of fracture retained was 14%compared with 5.6% for those fractures with the teeth in the line of fracture extracted.© 2009 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 67:804-808, 2009
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n minimally displaced linear fracture of the man-ibular angle there is a controversy regardinghich method is best for fixation. At our institu-

ion, the patient could either undergo closed reduc-ion and maxillomandibular fixation (MMF) for 4 to

weeks or open reduction and internal fixationORIF) with the Synthes 2.0-mm 8-hole curved strut

eceived from the Department of Oral and Maxillofacial Surgery,

he University of Texas Health Science Center—Houston, Hous-

on, TX.

*Former Chief Resident.

†Assistant Professor.

‡Second-Year Dental Student.

Address correspondence and reprint requests to Dr Demian:

epartment of Oral and Maxillofacial Surgery, The University of

exas Health Science Center—Houston, Dental Branch, 6516 MD

nderson, Houston, TX 77030; e-mail: [email protected]

2009 American Association of Oral and Maxillofacial Surgeons

278-2391/09/6704-0014$36.00/0

coi:10.1016/j.joms.2008.08.034

804

late (Synthes, Paoli, PA) (Fig 1). This system haseen used only in a few centers in the Unitedtates. The main advantages of this plating systemre minimal risk to inferior alveolar nerve injury, itstability in 3 dimensions, low profile (which re-uces soft tissue disturbance), and palpability, mal-

eability, and torque resistance.1 When fixatingone segments, the surgeon only needs to place 1late instead of 2 separate plates as are often used

or this type of fracture. It theoretically reduces theperative time, which is important for many sur-eons. To our knowledge, there has been only 1ublished paper describing the application of thisystem in mandibular fracture without specificallyooking at the efficacy of extraction of teeth in theine of fracture. The mentioned paper showed aow infection rate associated with this procedure5.4%).1 The purpose of this study is to determinehe rate of infection associated with mandibularngle fractures repaired with a 2.0-mm 8-hole
urved strut plate, whether a presence of teeth in
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BUI, DEMIAN, AND BEETAR 805

he line of fracture increased the rate of infection,nd whether removal of teeth in the line of fractureffects the rate of infection.

aterials and Methods

The study is a retrospective review of fractures ofandibular angles treated with 2.0-mm 8-hole strutlates at the Lyndon Baines Johnson General Hospital

rom 2003 to 2007. After exposure and reduction ofhe fracture via an intraoral incision similar to inci-ions used in cases of mandibular sagittal split osteot-mies or vertical ramus osteotomies, the strut plate isositioned perpendicularly to the fracture line, and

ies midway superior-inferiorly between the superiornd inferior borders of the mandible. Fixation is car-ied out with 5- or 6-mm monocortical screws percu-

IGURE 1. A 2-mm 8-hole curved strut plate made by Synthesaxillofacial.

ui, Demian, and Beetar. Infection Rate in Mandibular Angleractures. J Oral Maxillofac Surg 2009.

IGURE 2. Ideal placement of strut plate across the fracture line.


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aneously via a trocar and cheek retractor systemrovided by the manufacturer (Fig 2). Data were col-

ected from a surgical log book from the Departmentf Oral and Maxillofacial Surgery, and from the hos-ital medical records. Inclusion criteria include hav-

ng follow-up appointments for at least 4 weeks, com-liance with a nonchewing diet for 4 to 6 weeks, andbsence of fracture comminution. Data for all selectedatients include information such as age, gender, eti-logy of injuries, medical history, concurrent injuries,erve deficits, pre- and postoperative antibiotic ad-inistration, infection, presence or absence of teeth

n the line of fracture and whether these teeth wereemoved, and pre- and postoperative panoramic x-ays (Figs 3, 4). Criteria for extraction of teeth in theine of fracture at our institution include fracture ofnvolved teeth, gross dental caries, and exposure of0% or more of tooth roots, pericoronitis, periodontal

nfection, and interference with adequate reductionf a fracture. The primary adverse outcome investi-ated in this study was postoperative infection. Thereas also a set of databases on secondary adverseutcomes including malocclusion, nerve injury, andailed hardware. We compared the infection rate be-ween a presence and an absence of teeth in the linef fracture, and between a retention and extraction ofhese teeth. Because of the nonrigid nature of thisype of fixation, we placed the patients in MMF for a

IGURE 3. Preoperative panoramic x-ray showing a displacedandibular angle fracture.


IGURE 4. Panoramic x-ray showing good placement of a strutlate.


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806 INFECTION RATE IN MANDIBULAR ANGLE FRACTURES

eriod of 2 weeks. Arch bars and stainless steel wireslaced at the beginning of the procedure are notemoved until 6 weeks after the procedures if theostoperative course was unremarkable. These barsnd wires can be used for extended fixation or touide the occlusion with elastics if needed.

esults

Forty-nine patients (90% male and 10% female) methe criteria and were included in the study. The meange was 26 years old, with 20% younger than 20 yearsld; 44% were between 20 and 30 years old, 24% wereetween 30 and 40 years old, and 12% was older than0 years old (Table 1). Fifty-nine percent of the pa-ients had angle fractures on the left side and 8% hadilateral angle fractures. The duration of follow-upas from 4 to 24 weeks. Eighty-two percent of theatients had fractures resulting from aggravated as-aults. The remaining fractures were a result of sport-elated injuries or automobile accidents. All patientsere prescribed oral preoperative antibiotics until

urgery and postoperative antibiotics for 7 to 10 days.orty percent of the patients reported the use ofllegal drugs, 44% of the patients admitted to the usef alcohol, and 50% of the patients were smokers.ost patients had their surgeries between postinjuryay 3 and 7. All patients were placed on a nonchew-

ng diet preoperatively and postoperatively to a totalf 6 weeks after surgery. Sixty-five percent of patientsad teeth in the line of fractures. Among them, 60%ad these teeth extracted based on the predeter-ined criteria for extraction used at our institution.

our patients (8.2%) developed infections. Two infec-ions were associated with teeth in the line of fracturehat were retained (2 of 14 or 14%), the third wasssociated with a tooth in the line of fracture that wasxtracted (1 of 18 or 5.6%), and the fourth did notave an associated tooth in the line of fracture (1 of7 or 5.9%) (Table 2). The overall complication rate isof 49 or 8.2%.

iscussion

Mandibular angle fractures can be treated in a

Table 1. DEMOGRAPHIC DATA

CharacteristicsTeeth Not in the Line o

(N � 17)

ge 17-52 (mean age 2ender 1 female, 16 maleoncurrent mandibular fractures 9 patients

ui, Demian, and Beetar. Infection Rate in Mandibular Angle F

losed or open fashion. Closed treatment requires theBF

atient to be in MMF for 4 to 6 weeks or even longern older patients or patients with comminuted frac-ures. This prolonged MMF can be problematic inatients with psychiatric disorders or patients at risk

or aspiration such as alcoholics or patients with al-ered mental status. Prolonged MMF can also lead totrophy of mastication muscles.2 ORIF can eliminater reduce the period of MMF and facilitate an earlyeturn of jaw function. Immobilization of fractureegments can be achieved via rigid fixation with dynamicompression plates (DCPs), reconstruction plates, lagcrews, or via semirigid fixation with monocorticaliniplate osteosynthesis. DCP was one of the firstethods of fixation used to treat angle fractures. Ideallacement of DCP is along the inferior border torevent damage to roots of the teeth in the areas. Thislacement may cause distraction of the superior as-ect of the mandible during jaw function, which cane negated with a small tension plate in the superiorurface of the fracture site. The DCP system obviouslyoes not work well in fractures that are oblique oromminuted or with continuity defect. In these in-tances, surgeons may consider reconstruction plateshat are thicker and therefore provide greatertrength that would resist functional load better.2 In aaper published in JOMS in 1993, Ellis3 found that the

nfection rate associated angle fractures fixated witheconstruction plates was relatively low (7.5%),hich has served as a benchmark for ORIF of the

ngle fracture. When dealing with a linear fracture of

ure Teeth in the Line of Fracture (N � 32)

Retained Teeth Group (N � 14) Extracted Teeth Group (N � 18)

16-46 (mean age 25) 15-45 (mean age 26)1 female, 13 male 3 female, 15 male7 patients 10 patients

s. J Oral Maxillofac Surg 2009.

Table 2. OUTCOME OF THE TREATMENT

Outcome

Teeth Notin the Lineof Fracture(N � 17)

Teeth in the Line ofFracture (N � 32)

RetainedTeeth Group

(N � 14)

ExtractedTeeth Group

(N � 18)

nfection rate 1 2 1ailed hardware 0 0 0alocclusion 0 0 0al/nonunion 0 0 0

atrogenic nerveinjury 0 0 0

f Fract

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BUI, DEMIAN, AND BEETAR 807

he mandibular angle, surgeons may choose to place ainiplate along the external oblique ridge to neutral-

ze the tensile force in the superior aspect of theandible, which has been known as the Champy

echnique. The placement of these plates requiresess dissection of tissue, and theoretically leads to aeduction of infection rate and time of operation.lood supply to the mandible is preserved, and risk ofoot injury is eliminated. However, this system is onlysemirigid fixation so soft diet or even 1 to 2 weeksf MMF should be instituted to prevent torsionalovements of the segments. To minimize torsional

orces, some authors recommend a second plate athe inferior border of the mandible, which negateshe advantage of minimal dissection associated withhe Champy technique and prolongs operative time.n addition, the complication rate is found to be muchigher with the 2 miniplates in treatment of the angleractures (29%).4 Recently, a 3D 2.0-mm 8-hole strutlate system has been used in several centers in thenited States, which has shown very promising data.n article published in JOMS in 2005 by Guimond etl1 showed an infection rate associated with this sys-em to be around 5.4%, which is relatively low. Theationale for using this plating system is the simplicityf its application because of its malleability, low pro-le (reduced palpability), and ease of application (re-uires little or no additional contouring). Surgeonsnly need to place 1 plate instead of 2 as often used,hich theoretically reduces the operative time and

till achieves the benefit of a 2-plate system. With thisystem, there is minimal risk of inferior alveolar nervenjury. In addition, several studies have implied that

icromotion created by smaller plates may aid boneealing.5,6 However, the study by Guimond et al1 didot specifically address the effect of removal of teeth

n the line of mandibular angle fractures.Mandibular angle fracture is known to be associatedith a higher postoperative infection than any other

ype of fracture. The incidence has been reported asigh as 32%.7 There are several reasons for the higherate of infection, including the presence of a tooth in theine of fracture. In an article published in JOMS in 2002,llis7 compared the rate of postoperative infection in theandibular angle fractures between the fractures with,

ersus without, teeth in the line of fracture, and heound that there was a 3% higher infection rate whenhere was a tooth in the line of fracture, although theifference was not statistically significant. These frac-ures were treated by 6 different techniques (a 2.0-mminiplate, a 1.3-mm miniplate, a 2.0-mm lockinginiplate, 2 DCPs, 2 2.0-mm miniplates, and 2 2.4-mmCPs), making the comparison more complex. Theirriteria for extraction of teeth in the line of fracture areimilar to the criteria used at our institution. Teeth in the
ine of fracture are removed if they interfere with reduc- p
ion of the fracture, are fractured, infected, have grossaries, significant mobility, or exposure of 50% or moref the root surface.7 To the best of our knowledge, ourtudy is the first study that specifically compares thenfection rates between the presence versus absence ofeeth in the line of fracture in mandibular angle fracturesreated with 2.0-mm 8-hole strut plates.

One of the patients who developed an infection was46-year-old male who was initially treated with a

losed reduction for a right subcondylar and left man-ibular angle fractures. He self-released the MMF withinweeks to be able to have a regular diet against post-

urgical instructions. Later, he developed malocclusionnd pain. The angle fracture was then fixated with a 2.0trutplate and the subcondylar fracture was treatedlosed with guiding elastics. The mandibular left thirdolar, which was in the line of fracture, was retained.ithin 2 weeks of treatment, the patient resumed a

egular diet and removed his elastics. Additionally, heid not adhere to specific oral hygiene instructions norid he take the prescribed antibiotics. He subsequentlyeveloped an infection involving the repaired angle frac-ure, requiring an incision and drainage and replace-ent of the strut plate with a reconstruction plate. Asith any semirigid fixation method, it is very important

hat the patient complies with a nonchewing diet for 6eeks to achieve a desirable outcome. A diet requiringastication will place undue stress on the strut plate,hich may lead to failure. The correlation between

hronic diseases, drug abuse, and smoking, and risk ofeveloping infection in patients with mandibular frac-ures has been described in a study by Malanchuk et al.8

n reviewing 789 patients with mandibular fractures, theuthors found a significantly higher infection rate42.7%) in the patient group with the above risk factorsompared with the other group (22.4%). Interestingly,he 4 patients that developed infection in our study allad been abusing drugs and smoking. One of them waslso taking immunosuppressive drugs because of rheu-atoid arthritis.In conclusion, there is a low complication rate

8.2%) associated with the use of a 3D 2.0-mm 8-holeurved strut plate in the treatment of uncomplicatedandibular angle fracture. This complication rate is

lightly higher than the finding in the study byuimond et al,1 and compares favorably against the

nfection rate (7.5%) in a study by Ellis.3 However, ifne were to exclude the patient mentioned above be-ause of noncompliance with the nonchewing diet, theverall rate of infection would drop to 6.2% and the ratef infections among all 3 groups would have been sim-

lar. The infection rate increase is consistent with Ellis’ndings of a 3% increase because of the presence ofeeth in the line of fracture. At our institutions we havead a favorable experience using the 2.0 curved strut
late to treat a linear mandibular angle fracture with a

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808 INFECTION RATE IN MANDIBULAR ANGLE FRACTURES

elatively low rate of complications. Although the infec-ion rate seemed significantly increased in the groupith retained teeth in the line of fracture, the size of theatients’ samples and the presence of other factors suchs noncompliance with postoperative instructions, doot allow recommending blanket extraction of teeth inhe line of fracture. We recommend following the pre-iously mentioned criteria to determine if removal ofeeth in the line of fracture is indicated, until such timehen the findings of this study are subjected to the

crutiny of larger more randomized studies.

eferences. Guimond C, Johnson JV, Marchena JM: Fixation of mandibular

angle fractures with a 2.0-mm 3-dimensional curved angle strut
plate. J Oral Maxillofacial Surg 63:209, 2005
. Baker S, Betts NJ: OMS Knowledge Update (Vol 2). AAOMSPublications at CS1616, Alpharetta, GA, 1998, p. TRA 11-27

. Ellis E: Treatment of mandibular fractures using two 2.4-mmdynamic compression plates. J Oral Maxillofac Surg 51:969,1993

. Siddiqui A, Markose G, Moos KF, et al: One miniplate versus twoin management of mandibular angle fractures: A prospectiverandomized controlled study. Br J Oral Maxillofac Surg 45:223,2007

. Kummer FJ: Craniomaxillofacial bone healing, biomechanics,and rigid internal fixation, in Greenberg AM, Prein J (eds):Craniomaxillofacial Reconstructive and Corrective Bone Sur-gery. New York, Springer, 2002, p. 101

. Champy M, Pape H-P, Gerlach KL, et al: Mandibular fractures, inKruger E, Schilli W (eds): Oral and Maxillofacial Traumatology(Vol 2). Chicago, Qunitessence, 1986, p 10

. Ellis E: Outcomes of patients with teeth in the line of mandibularangle fractures treated with stable internal fixation. J Oral Max-illofac Surg 60:863, 2002

. Malanchuk VO, Kopchak AV: Risk factors for development ofinfection in patients with mandibular fractures located in the
tooth-bearing area. J Cranio-Maxillofac Surg 35:57, 2007

infection rate in mandibular angle fractures treated with a 2.0-mm 8-hole curved strut plate

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