J Oral Maxillofac Surg

63:655-663, 2005

Treatment Modalities for Mandibular

Angle Fractures
Andrew J.L. Gear, MD,* Elena Apasova, MD,† John P. Schmitz, DDS, PhD,‡ and
Warren Schubert, MD§
Purpose: Management of mandibular angle fractures is often challenging and results in the highest
complication rate among fractures of the mandible. Optimal treatment for angle fractures remains
controversial. Historically, treatment of mandible fractures included intraoperative maxillomandibular
fixation (MMF) along with rigid internal fixation. More recently, noncompression plates miniplates,
which produce only relative stability, have gained popularity. The absolute necessity of intraoperative
MMF as an adjunct to internal fixation has also become controversial. The current trends in the
management of simple, noncomminuted mandibular angle fractures are examined.
Materials and Methods: A survey was submitted to North American and European AO ASIF (Arbeits-
gemeinschaft für Osteosynthesefragen Association for the Study of Internal Fixation) faculty in July 2001.
Statistical analysis of results included both Fisher’s exact and chi-square tests. Results were considered
significant if P ⬍.05.
Results: One hundred ten of 127 potential responses were received (87%). Among 104 surgeons who treat
mandible fractures, 86 (83%) treat more than 10 mandibular fractures per year. Preferred techniques for
simple, noncomminuted mandibular angle fractures in this group were: single miniplate on the superior
border (Champy technique) with or without arch bars (44 surgeons, 51%); tension band plate on the superior
border and nonlocking, bicortical screw plate on the inferior border (11 surgeons, 13%); dual miniplates (9
surgeons, 10%); a locking screw plate on the inferior border only (6 surgeons, 7%), and 3-dimensional plates
(5 surgeons, 6%). Eleven surgeons (13%) gave multiple answers. Although only 13% of surgeons surveyed
primarily use the combination of tension band and nonlocking, bicortical screw plates, many surgeons (73%)
continue to use this technique in certain circumstances. Within this group, 32 (51%) place screws in a neutral
position, while 31 (49%) place screws in an eccentric position, resulting in compression. For simple
noncomminuted angle fractures, the number of surgeons performing internal fixation without MMF were: 14
often (16%); 20 occasionally (23%); 17 seldom (20%); and 35 never (41%). Surgeons treating more than 10
versus those who treat less than 10 fractures per year, International versus North American faculty, and Oral
and Maxillofacial surgeons (OMS) versus non-OMS surgeons were compared. Surgeons who treat more than
10 fractures per year favor the Champy technique over the tension band and bicortical plate combination (44
[51%] vs 11 [13%]), while those surgeons who treat less than 10 per year favor the tension band and bicortical
plate combination over the Champy technique (9 [50%] vs 3 [17%]; P ⬍ .01, Fisher exact test). International
faculty are less likely to use intraoperative MMF than North American faculty (29 [81%] vs 31 [43%]; P ⬍ .01,
Fisher exact test). OMS surgeons are less likely to use the tension band and bicortical plate combination than
non-OMS surgeons (22 [56%] vs 42 [90%]; P ⬍ .017, Fisher exact test).
Conclusion: This survey suggests an evolution in the management of mandibular angle fractures. A
single miniplate plate on the superior border of the mandible has become the preferred method of
treatment among AO faculty. When using large, inferiorly based plates more surgeons are now favoring
neutral rather than eccentric screw placement. Intraoperative MMF is not considered mandatory by some
surgeons in certain circumstances.
© 2005 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 63:655-663, 2005

*Plastic Surgery Resident, University of Minnesota and Regions Address correspondence and reprint requests to Dr Schubert:
Hospital, Department of Plastic and Hand Surgery, Saint Paul, MN. Department of Plastic and Hand Surgery, Regions Hospital, 640
†Surgery Resident, University of Minnesota and Regions Hospital, Jackson St, Saint Paul, MN 55101.
Department of Plastic and Hand Surgery, Saint Paul, MN. © 2005 American Association of Oral and Maxillofacial Surgeons
‡Private Practice, San Antonio, TX. 0278-2391/05/6305-0074$30.00/0
§Associate Professor, University of Minnesota and Regions Hos- doi:10.1016/j.joms.2004.02.016
pital, Department of Plastic and Hand Surgery, Saint Paul, MN.

655
656 TREATMENT FOR MANDIBULAR ANGLE FRACTURES

Open reduction and internal fixation (ORIF) of the

mandible with bone plates was first described by
Schede in 1888, who used steel plates and screws.1
Early attempts at ORIF were marred by poor results
because of metal corrosion and fatigue, along with
screw failure causing nonunion. External techniques
predominated until the 1960s when Luhr introduced
Vitallium compression plating.2,3 Luhr, Spiessl,5
Schmoker6 and others derived inspiration from ortho-
pedic biomechanical studies performed by Schenk4
which suggested accelerated bone healing through
compression. The evolution of internal fixation was
aided by the discovery of biocompatible materials that
resisted corrosion, such as Vitallium and titanium.
During the early 1970s, Schmoker and Spiessl devel-
oped dynamic compression plating for the mandible, FIGURE 2. The mandible possesses variable zones of tension and
which used eccentrically placed screws to generate compression, with tension (⫺) on the superior border and compression
compression (Fig 1).6-8 Simultaneously, Michelet et (⫹) on the inferior mandibular border.
Gear et al. Treatment for Mandibular Angle Fractures. J Oral
Maxillofac Surg 2005.

al9,10 began experimenting with monocortical non-

compression miniplates. Using a simple cantilever
beam model, Champy et al11-19 showed that the su-
perior mandibular border was subject to tension and
splaying, and the inferior border was subject to com-
pression (Fig 2). The transition zone between areas of
tension and compression has been referred to as a
“line of zero force” running along the inferior alveolar
nerve (Fig 3). Based on these biomechanical findings,
Champy recommended a single noncompression
miniplate on the superior border for mandibular angle
fractures (Champy technique) (Fig 4).

FIGURE 3. Depiction of a biomechanical model of the mandible,

FIGURE 1. Depiction of compression that is created with eccentrically where “a line of zero force” (or fulcrum) separates a zone of tension on
placed screws. This concept was originally developed for long bone the superior mandibular border from a zone of compression on the
fixation and was adapted to the mandible using an eccentric, dynamic inferior border. This line of zero force mirrors the course of the inferior
compression plate. alveolar nerve.
Gear et al. Treatment for Mandibular Angle Fractures. J Oral Gear et al. Treatment for Mandibular Angle Fractures. J Oral
Maxillofac Surg 2005. Maxillofac Surg 2005.
GEAR ET AL 657

for bone healing, and the necessity of intraoperative

MMF as an adjunct to ORIF. In light of these issues, we
submitted a survey to assess current trends in man-
dibular angle fracture management.

Materials and Methods

A survey was submitted to 127 members of the
North American and European AO ASIF (Arbeitsge-
meinschaft für Osteosynthesefragen, Association for
the Study of Internal Fixation) faculty between July
and September 2001 (Table 1). AO ASIF, often abbre-
viated as AO, is a Swiss-based nonprofit foundation
dedicated to the study and teaching of techniques of
internal fixation. AO membership includes academic
surgeons from the various specialties involved with
trauma, orthopedics, maxillofacial surgery, spine,
hand, and the veterinary sciences. The maxillofacial
branch of AO is composed of surgeons from the
FIGURE 4. Champy technique: a single miniplate is placed on the specialties of plastic surgery, oral and maxillofacial
superior border for an angle fracture. surgery, otolaryngology, and a smaller number of gen-
Gear et al. Treatment for Mandibular Angle Fractures. J Oral eral surgeons, occuloplastic surgeons, and neurosur-
Maxillofac Surg 2005. geons.
Data were collated and tabulated using Microsoft
Excel (Microsoft Corporation, Redmond, WA). Statis-
Beginning in the mid-1970s, Niederdellmann et tical analysis of results was performed using both
al20-23 pursued a radically different treatment modality Microsoft Excel (Microsoft Corporation) and SSPS
using a lag screw, which also generated fracture sta- (SPSS Inc, Chicago, IL), and included both Fisher
bility through compression without the use of plates exact and chi-square testing. Results were considered
(Fig 5). Lag screws have proven to be technically statistically significant if P ⬍ .05.
difficult and have thus not gained popularity. Sur-
geons in North America who have tried this tech-
Results
nique have extracted the third molar before placing
the lag screw. On the other hand, Niederdellmann et One hundred ten responses of 127 surveys were
al placed the lag screw through the third molar and received (86%). Eighty-six surgeons (83%) stated that
later removing both the screw and tooth after fracture
healing.
Angle fractures generate the highest frequency of
complications relative to other mandibular fractures,
ranging from 0% to 32%.24-29 The optimal treatment of
angle fractures remains controversial. Traditional
treatment protocols for angle fractures involved rigid
fixation in conjunction with intraoperative maxillo-
mandibular fixation (MMF) to produce absolute sta-
bility with primary bone union and immediate post-
operative function. Unfortunately, few prospective,
randomized studies of operative technique have been
performed. Published studies, a majority of which
were nonrandomized and retrospective, produced in-
consistent results.29-39 Biomechanical models of man-
dible fractures have also generated conflicting re-
sults.18,19,40-45 Unresolved controversies surrounding FIGURE 5. The lag screw technique as described by Niederdell-
mann et al.20 The proximal and distal bone segments are drilled with
the treatment of mandibular angle fractures include differing sized bits so that the screw slides through the proximal portion
the effectiveness of traditional plating techniques em- while gaining purchase of the distal segment.
phasizing larger plates with bicortical screws in com- Gear et al. Treatment for Mandibular Angle Fractures. J Oral
parison to miniplates, the necessity of compression Maxillofac Surg 2005.
658 TREATMENT FOR MANDIBULAR ANGLE FRACTURES

Table 1. SURVEY OF TREATMENT MODALITIES FOR MANDIBLE ANGLE FRACTURES

1. How many mandible fractures do you treat in 1 year? (please circle)

a. None
b. 1–5
c. 6–10
d. ⬎ 10
2. For a simple, noncomminuted mandibular angle fracture, what is your preferred method of treatment?
a. Arch bars alone
b. Champy technique
c. Champy technique ⫹ arch bars
d. Two miniplates
e. Tension band plate ⫹ bicortical plate (nonlocking screw plate)
f. Locking screw plate
g. Tension band plate ⫹ locking screw plate
h. Lag screw technique
i. Other (please specify)
i. 3D plate
ii. Open approach with neutral, universal plate?
j. Multiple answers
3. Do you ever use a tension band plate along with a bicortical plate?
a. Yes
b. No
4. If the answer to question 3 is yes, do you:
a. Prefer the screws in the bicortical plate to be in a neutral position?
b. Prefer the screws to be in an eccentric position to allow compression?
5. If you have a simple, linear, noncomminuted mandible fracture in a patient with good dentition and normal occlusion,
would you perform an ORIF without intraoperative MMF?
a. Never
b. Seldom
c. Occasionally
d. Often
6. If the answer to question 5 is affirmative, what complications have you experienced?
7. Do you commonly have residents present during your cases?
a. Yes
b. No
Gear et al. Treatment for Mandibular Angle Fractures. J Oral Maxillofac Surg 2005.

they treat more than 10 mandibular fractures per year plate, 63 surgeons (73%) said yes and 23 (27%) said no
and that their preferred techniques for simple, non- (P ⬍ .0001, chi-square test). Of surgeons using ten-
comminuted angle fractures were as follows: sion band and bicortical plates, 32 (51%) placed

1. Champy technique without arch bars (27

[31%]) (Fig 4).
2. Champy technique with arch bars (17 [20%])
(Fig 6).
3. Tension band plate with a bicortical plate (11
[13%]) (Fig 7).
4. Dual miniplates (9 [10%]) (Fig 8).
5. Locking screw plate (6 [7%]) (Fig 9).
6. Three-dimensional (3D) plating (square or rect-
angular plates) (5 [6%]).

Eleven surgeons (13%) gave multiple answers in ref-

erence to preferred technique. The results of the
preferred technique for surgeons are showed in Fig-
ure 10.
Among surgeons who treat more than 10 mandible FIGURE 6. Champy technique with Erich arch bars.
fractures per year, when asked if they ever use a Gear et al. Treatment for Mandibular Angle Fractures. J Oral
tension band plate in combination with a bicortical Maxillofac Surg 2005.
GEAR ET AL 659

FIGURE 7. Original AO method for ORIF using a compression plate

with bicortical screws on the inferior mandibular border and a tension
band plate with monocortical screws on the superior border. FIGURE 9. Depiction of a locking screw plate. Note the unique
Gear et al. Treatment for Mandibular Angle Fractures. J Oral screw configuration that possesses separate threads for the bone and
Maxillofac Surg 2005. the plate. This allows the screw to engage the plate and serve as an
internal– external fixator. Traditional screws essentially lag the plate to
the bone, whereas the locking screw anchors the plate in a manner
screws in a neutral position, while 31 (49%) place that increases 3D stability. By allowing the screw to separately engage
the plate, perfect plate contour is unnecessary.
them in an eccentric manner (resulting in compres-
Gear et al. Treatment for Mandibular Angle Fractures. J Oral
sion). When asked whether they would perform ORIF Maxillofac Surg 2005.

without intraoperative MMF, surgeons treating more

than 10 fractures per year answered as follows: 35
never (41%); 17 seldom (20%); 20 occasionally (23%);
and 14 often (16%) (P ⬍ .002, chi-square test). Ninety-
seven surgeons (93%) had residents present during
their cases (P ⬍ .0001, chi-square test).
Statistical comparisons were then performed
among the following groups: surgeons who treat
more than 10 versus those who treat less than 10
mandibular fractures per year; International versus
North American AO faculty; and OMS versus non-OMS
faculty. Surgeons who treat more than 10 mandible
fractures per year favor the Champy technique over
the combination of tension band and bicortical plates
(44 [50%] vs 11 [13%]), while those surgeons who
treat less than 10 fractures per year favor the tension
band and bicortical plate combination over the
Champy technique (9 [50%] vs 3 [17%]) (P ⬍ .01,
FIGURE 8. Dual miniplates. Fisher exact test) (Fig 11). International AO faculty
Gear et al. Treatment for Mandibular Angle Fractures. J Oral are more likely to bypass intraoperative MMF than
Maxillofac Surg 2005. North American faculty (29 [81%] vs 31 [43%]) (P ⬍
660 TREATMENT FOR MANDIBULAR ANGLE FRACTURES

Do you ever use a tension band

along with a bicortical plate?
100
90
90
80
70
(% ) 60 56
yes
50 44 no
40
30
20
10
10
0

OMS Non-OMS

P = 0.017 (Fisher Exact Test)

FIGURE 12. OMS-trained surgeons are less likely to use the tension
band and bicortical plate combination than non-OMS surgeons (56%
FIGURE 10. Among surgeons who treat more than 10 mandible vs 90%).
fractures per year, the preferred techniques for simple, noncomminuted
angle fractures were as follows: 1) Champy technique (single mini- Gear et al. Treatment for Mandibular Angle Fractures. J Oral
plate along the superior border of the mandible) with or without arch Maxillofac Surg 2005.
bars (51%); 2) tension band plate along with a bicortical screw compres-
sion plate (13%); 3) dual miniplates (10%); and 4) locking screw plate
(7%). Note that 51% of surgeons use the Champy technique. anteriorly, and the presence of the third mo-
Gear et al. Treatment for Mandibular Angle Fractures. J Oral Max- lars.46,47 Treatment of angle fractures is plagued by
illofac Surg 2005. the highest complication rates among mandible
fractures, and no consensus exists regarding opti-
.01, Fisher exact test). Finally, OMS surgeons are less mal treatment.24-26,48,49
likely to use the tension band and bicortical plate As a result of early research in long bones, AO
combination than non-OMS surgeons (22 [56%] vs 42 initially stressed the need for absolute stability to
[90%]) (P ⬍ .017, Fisher exact test) (Fig 12). prevent fragment mobility and generate primary bone
healing.38,39 Reconstruction plates, lag screws, and
2-plate systems were all developed to achieve primary
Discussion bone healing. The original AO technique involved
Mandibular angle fractures are common.25,26 Rea- placement of superior and inferior border compres-
sons for this may include a thin cross-sectional area sion plates for angle fractures. A later modification
relative to the body, symphysis and parasymphysis used a noncompression tension band plate on the
superior border and a compression plate on the infe-
rior border. Postoperative complications such as in-
fection and malunion were attributed to inadequate
fixation and fragment mobility.39
In 1973, Michelet et al10 described the treatment of
mandibular fractures using small, easily bendable,
noncompression miniplates placed transorally and an-
chored with monocortical screws. This technique
contradicted the AO and Luhr’s emphasis on com-
pression and absolute rigidity. Champy later per-
formed a series of experiments with miniplates that
delineated “ideal lines of osteosynthesis” within the
mandible (Fig 13).11,12,14,16,18 Plates placed along
these lines were thought to provide optimal fixation
and stability. Ideal plate placement for angle fractures
FIGURE 11. Surgeons who treat less than 10 mandible fractures per
was along the superior border of the mandible above
year favor the tension band and bicortical compression plate combi- or just below the superior oblique ridge. Because
nation over the Champy technique (50% vs 17%), while surgeons who these plates were small and the screws monocortical,
treat more than 10 mandible fractures per year favor the Champy
technique over the tension band and bicortical plate combination
placement was possible without damaging the tooth
(51% vs 13%). roots.
Gear et al. Treatment for Mandibular Angle Fractures. J Oral Subsequent clinical studies corroborated the effec-
Maxillofac Surg 2005. tiveness of the Champy technique.31,38,39,50-54 Ellis et
GEAR ET AL 661

sequent pseudarthrosis requiring secondary fixation

with another rigid plate, no major complications in
bone healing were observed in group 3. Although
Ehrenfeld et al’s study was not limited to mandibular
angle fractures, it is one of the only prospective and
randomized studies involving ORIF of mandible frac-
tures. The conclusions suggested that smaller non-
compression plates lowered the complication rate.
Niederhagen et al54 performed a prospective study
of angle fracture treatment over an 8-year period. One
hundred eighty-three patients with mandibular frac-
tures were treated, noting 127 complications using
the standard traditional AO method compared with
41 complications using miniplates. The most frequent
complication was dehiscence. In addition, more com-
plications were noted (19.5%) when using the AO
technique via an intraoral approach. Comparison of
extraoral AO treatment and monocortical miniplates
showed no significant difference in complication rate
(8.1% vs 7.3%). During this study a transition was
made from the AO method to monocortical noncom-
FIGURE 13. Depiction of Champy’s ideal lines of osteosynthesis.
pression miniplates.54
Plates placed in proximity to these lines are thought to produce optimal Another controversy involved supplementation of
stability. Note that there are 2 possible locations for plate placement miniplate fixation with MMF.57,58 Many surgeons still
around the angle. Within the symphyseal or parasymphyseal areas,
Champy stressed the need for 2 plates to counter increased torsional
felt that miniplate fixation did not provide adequate
forces. stability and required MMF for additional security. In
Gear et al. Treatment for Mandibular Angle Fractures. J Oral a retrospective study of 287 patients with 499 man-
Maxillofac Surg 2005. dible fractures, Valentino and Marentette36 compared
130 patients who underwent intraoral monocortical
plating of matched fractures and found that the addi-
al29,32,33,35,51,55,56 examined various treatment modal- tion of MMF did not significantly alter complication
ities for angle fractures. They showed a significantly rates. Prein et al59 noted similar findings in a small
higher complication rate using compression plates on prospective study of 32 patients combining the old
both mandibular borders intraorally in comparison to AO technique with MMF.
the Champy technique.29 The Champy technique pos- The stability of single miniplate fixation of angle
sessed the lowest complication rates in 2 separate fractures was challenged by several biomechanical
studies (2.5% and 0%, respectively).39,51 Intraoral ap- studies based on 3D models. Kroon et al40 and Choi et
plication of larger plates appears to increase compli- al60 both observed bony gaps along the inferior frac-
cation rates. The reasons for this are unclear, but may ture border, and this fracture movement was thought
be partly because of the extensive degloving required to contribute to subsequent complications, including
for plate placement. Large plates are also more diffi- infection. A second plate was suggested to reduce
cult to contour to the mandible, and subsequent com- anterior-posterior separation of the fracture line as
pression can generate telescoping and fracture mal- well as lateral displacement, which is frequently ob-
alignment. served on postoperative radiographs.41 Ensuing clini-
In a prospective study by Ehrenfeld et al,53 150 cal studies were inconsistent, with an additional
adult patients with mandible fractures were analyzed. miniplate lowering, increasing, or not changing com-
Patients were equally distributed among 3 different plications rates.31,35,38 More recent 3D models have
treatment groups. Group 1 was treated with MMF. shown that the rotational or torsional forces at the
Displaced fractures that needed open reduction were angle are relatively weak.45
treated with wire osteosynthesis. Group 2 were Our survey highlights an evolution in the manage-
treated with rigid internal fixation with AO 2.7-plates ment of mandibular angle fractures. The Champy
using an intraoral approach, and group 3 had internal technique was developed in the 1970s and is used by
fixation with miniplates via an intraoral approach. surgeons in Europe and the United States.29,37,39,51
After an average of 2 years’ follow-up, group 1 had the Among AO faculty, many of whom had been trained
lowest complication rate, and group 2 had the high- using tension band and compression plating for angle
est. With the exception of 1 plate fracture with sub- fractures, over 50% now use the Champy technique
662 TREATMENT FOR MANDIBULAR ANGLE FRACTURES

for simple noncomminuted angle fractures. Level of who use bicortical plates place screws in the neutral
experience appears to correlate with use of this tech- position; 3) the number of mandible fractures treated
nique. Surgeons who treat more than 10 mandible per year influences the choice of treatment modality,
fractures a year clearly favor the Champy technique, with more experienced surgeons favoring the
while surgeons who treat less than 10 mandible frac- Champy technique while less experienced surgeons
tures a year continue to use the old AO standard. This favored tension band and bicortical plating; 4) Inter-
is ironic because most surgeons find the Champy national AO faculty, a majority of whom have OMS
technique faster and easier in comparison to the use training, will often attempt to repair linear and un-
of a tension and bicortical plate. It is also interesting complicated angle fractures without MMF.
to note that a significant number of oral and maxillo- It appears that many of the concepts surrounding
facial surgeons have discarded the original AO tech- the management of mandibular fractures are evolving.
nique in comparison to their non-OMS counterparts. This is evident in the transition from large, dual com-
The original AO technique remains valuable to sur- pression plates to a single miniplate as a favored
geons for certain angle fractures. When using this technique for simple mandibular angle fractures.
technique, 51% of faculty place screws in a neutral
position, rather than eccentrically. We believe this
trend away from eccentric screw placement and com- References
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