J Oral Maxillofac Surg

61:458-461, 2003

Treatment of Severe Mandibular Fractures

Using AO Reconstruction Plates
Paolo Scolozzi, MD, DMD,* and Michel Richter, MD, DMD†

Purpose: The goal of this study was to retrospectively evaluate the use of 2.4-mm AO titanium
reconstruction plates for mandibular fractures.
Patients and Methods: We analyzed the clinical and radiologic data of 63 patients with 63 single
fractures (53 comminuted, 5 dislocated, and 5 with bone loss) and 2 patients with double fractures.
Fracture location was symphysis in 37 patients (56.9%), body in 13 (20%), and angle in 15 (23.1%). We
recorded the mechanism of injury, time between injury and surgery, gender and age, temporary
maxillomandibular fixation (MMF) and its duration, and surgical approach. Follow-up examinations were
performed at 1, 3, 6, and 12 months, at which time we noted the status of healing and any complications.
Results: Fifty patients (77%) had a successful treatment outcome without complications; 13 patients
(20%) developed minor complications; and 2 patients (3%) developed nonunion with infection requiring
hardware removal and reosteosynthesis with bone graft.
Conclusions: We found that 2.4-mm AO titanium reconstruction plates can be used to treat severe
mandibular fractures with a low rate of major complications (3%) and a high success rate.
© 2003 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 61:458-461, 2003

According to the AO/ASIF principles, the goal of open precarious vascularity to the bone fragments, with a
reduction and internal fixation (ORIF) in the manage- resultant high incidence of infection, morbidity, and
ment of mandibular fractures is to achieve undis- technical problems. Some authors recommended
turbed healing and restoration of form and function open reduction techniques using Kirschner wire,
without the adjunctive use of maxillomandibular fix- transosseus wires, or bone plates.5,6
ation (MMF).1,2 This approach has become increas- Spiessl2 and Prein1 stressed 2 fundamental princi-
ingly popular during the past 15 years for all types of ples to obtain adequate rigid internal fixation for com-
mandibular fractures, including comminuted frac- minuted mandibular fractures. First, the fixation
tures, which historically have been treated with needs to support the full functional loads (load-bear-
closed reduction techniques. ing osteosynthesis). Second, absolute stability of the
Kazanjian3,4 appears to be the first author to stress fracture construct must be achieved. This is the pre-
that early fixation of fracture fragments is the most requisite for sound bone healing and a low rate of
important means of controlling infection and prevent- infection. These principles can be adhered to using
ing complications. This was well documented by his AO reconstruction or universal plates. However, tech-
experiences in World War I. Initially, open reduction nically in comminuted fractures, the bone fragments
of comminuted fractures was believed to be contra- can not take part in the functional load, and therefore
indicated because researchers feared impairing the load-sharing osteosynthesis between implant and bone
is not possible. The purpose of our study was to evaluate
the efficacy of 2.4-mm AO titanium reconstruction
Received from the Division of Reconstructive Surgery. Oral and plates in the treatment of mandibular fractures.
Maxillofacial Surgery Unit, Hôpitaux Universitaires de Genève, Ge-
nève, Switzerland.
*Senior Resident. Methods
†Professor, Head, Division of Reconstructive Surgery.
Address correspondence and reprint requests to Dr Scolozzi: In our study, 242 patients with 255 mandibular
Division of Reconstructive Surgery, Oral and Maxillofacial Surgery fractures were treated at the Hôpital Cantonal Univer-
Unit, Hôpitaux Universitaires de Genève, 24, Micheli-du-Crest, sitaire in Geneva between 1990 and 1999. Sixty-five of
1211 Genève 14, Switzerland; e-mail: [email protected] these patients underwent placement of 2.4-mm AO
© 2003 American Association of Oral and Maxillofacial Surgeons titanium reconstruction plates. The clinical and radio-
0278-2391/03/6104-0009$30.00/0 logic data from these 65 patients were retrospectively
doi:10.1053/joms.2003.50087 analyzed at follow up intervals of 1, 3, 6, and 12

458
SCOLOZZI AND RICHTER 459

Table 1. MECHANISMS OF INJURY Table 3. PATIENTS REQUIRING

MAXILLOMANDIBULAR FIXATION BY LOCATION
Etiology n %
Symphysis Body Angle Total
Traffic accident 31 47.7
Interpersonal violence 13 20 Maxillomandibular
Falls 8 12.3 fixation (n) 7 1 2 10
Sporting accident 6 9.2 Condylar fracture (n) 5 1 1 7
Gunshot wound 4 6.1 Malocclusion (n) 2 — 1 3
Work accident 3 4.6
Total 65 100

(range, 15 to 80 years) with a male predominance

months. Patients who were unable to return for up to (n ⫽ 55; 84.6%). The mean delay between injury and
12 months were excluded. surgery was 29.3 hours (range, 2 hours to 5 days). The
The variables reviewed included age and gender, mechanisms of injury are shown in Table 1.
mechanism of injury, delay between injury and sur- An extraoral approach was used in 41 patients
gery, location of the fracture, concomitant MMF and (63.1 %), particularly for body and angle fractures.
its duration, surgical approach, status of healing, and Symphyseal and parasymphyseal fractures were usu-
complications. Location of the fracture was classified ally treated via an intraoral approach (Table 2). Teeth
as symphyseal (between the canines), body (canine, were present in the fracture area in all but 1 patient
premolar, and molar region), and angle. Comminuted who was edentulous. In no cases were wisdom teeth
fractures were defined as the presence of more than 2 in angle fractures removed.
free bone fragments. Postsurgical complications that The AO mandibular reconstruction plate was fixed
were recorded as minor did not require surgical in- to each stable fragment with at least 3 bicortical
tervention and included hypoesthesia of V3 and mal- self-tapping screws. An adjunctive miniplate in the
occlusion. Major complications required further sur- alveolar region was used to stabilize multiple frag-
gical intervention and included infection and ments in 6 patients (9.2 %). Ten patients (15.4 %) with
nonunion. On admission, all patients were placed on an associated subcondylar fracture required postoper-
parenteral antibiotics (either amoxicillin 1 g 3 times ative MMF with traction elastics for 2 to 3 weeks
per day or amoxicillin and clavulonic acid 1.2 g 3 (Table 3). Thirteen patients (20 %) developed minor
times per day intravenously). The antibiotics were complications (Table 4). Two patients (3%) sustained
maintained for 3 days after surgery. Metal arch bars a nonunion requiring plate removal and reosteosyn-
(Dautrey type; Nichrominox, Lyon, France) were thesis with autologous iliac bone graft. We did not
placed in all patients, and intraoperative MMF was note any dental necrosis due to a screw within the
established before the fractures were reduced. The dental root. None of the patients who underwent an
MMF was routinely removed at the end of the surgery, extraoral approach noted dissatisfaction with the scar
except in the presence of unilateral or bilateral con- or developed permanent facial nerve paresis.
dylar fractures. In these cases, light traction elastics
replaced the MMF for an additional 2 or 3 weeks.
Discussion
The low incidence of major complications in this
Results
study corroborates one of the most important princi-
The study included 65 patients, of whom 53 had ples of the AO/ASIF group, that is, susceptibility to
comminuted fractures, 5 had fractures associated infection is related to mobility of the bone fragments.
with bone loss, 5 had dislocations, and 2 had bilateral Lack of adequate stabilization leads to chronic inflam-
fractures. The mean age of the patients was 34.3 years mation, which impairs the normal healing process

Table 2. LOCATION OF THE FRACTURES

Approach
Location Comminuted With Bone Loss Dislocated Bilateral Extraoral Intraoral

Symphysis (n) 33 2 1 1 17 20
Body (n) 10 2 — 1 11 2
Angle (n) 10 1 4 — 13 2
Total 53 5 5 2 41 24
460 TREATMENT OF SEVERE MANDIBULAR FRACTURES

Table 4. MINOR COMPLICATIONS BY LOCATION

Treatment of comminuted mandibular fractures by
ORIF was previously regarded with skepticism, espe-
Symphysis Body Angle Total cially because researchers believed that extensive
(n) (n) (n) (n) stripping of the periosteum from small bone frag-
ments would affect their vascularity, resulting in in-
Hypoesthesia V3 5 1 3 9
Malocclusion 4 — — 4 fection or nonunion. Consequently, closed tech-
Total 9 1 3 13 niques with occlusion as the key for reduction and
stabilization were the standard treatment. It is well
documented that better training diminishes postsur-
gical complications.17-19 This is particularly true for
and can result in delayed union, nonunion, or infec- such a demanding technical procedure as the correct
tion.7 Multiple, displaced, and comminuted fractures placement of AO reconstruction plates.
are especially prone to develop such problems be- The literature contains only a few references of
cause of the difficulty in obtaining sufficient immobi- surgical complications that occur following ORIF of
lization of the fragments. Other important factors, comminuted mandibular fractures with AO recon-
however, also affect outcome. These include mecha- struction plates. Smith and Johnson8 reviewed 16
nism of injury, delay between injury and treatment, consecutive comminuted fractures treated with 2.7-mm
and surgical expertise. AO stainless steel reconstruction plates. Two patients
Regarding mechanism of injury, almost one half of (13%) developed an infection that required plate re-
our patients were injured in traffic accidents. Inter- moval but did not require bone grafting. A deficit of
personal violence was responsible for the fractures in the marginal branch of the facial nerve occurred in 5
only 20% of patients, in contrast to a number of patients (33%), and hypoestesia or anesthesia in men-
reports in the literature from North America in which tal nerve distribution in 7 patients (47%). Ellis9 re-
interpersonal violence was the principal cause of in- ported on 31 comminuted angle fractures in his series
jury.8,9 Victims of interpersonal conflicts frequently of 52 angle fractures treated with 2.7-mm AO stainless
live in a precarious economic state, which may play a reconstruction plates via an extraoral approach. The
role in oral hygiene status, substance abuse, and ad- overall infection rate was of 7.5%. These infections
herence, all of which can affect fracture healing. Pas- were treated using extraoral incision, drainage, and
seri et al10 clearly showed that chronic substance antibiotics. The plate was removed in only 1 patient.
abuse affects the treatment outcome for mandibular Four patients (7.5%) experienced some slight maloc-
fractures, and this has also been reported by oth- clusion requiring 2 to 3 weeks of elastic traction. The
ers.11,12 In our study, the only 2 patients who devel- author did not note any facial or mental nerve deficits.
oped infection and nonunion presented with a com- Larger retrospective series report on generic man-
minuted fracture resulting from a low-velocity dibular fractures. Therefore, the incidence, treatment,
gunshot injury, an extremely rare cause of mandibular and complications of patients with comminuted frac-
injury in our country. Neupert and Boyd13 reported tures must be carefully extrapolated and evaluated.
that these fractures are associated with the highest Iizuka et al17 reported an infection rate of 6.1% when
rate of infection when located in the tooth-bearing using the AO/ASIF principle of rigid fixation. The
area and when overly aggressive wound debridement authors did not separately analyze the comminuted
is performed. In a series of 32 patients who sustained fractures treated with reconstruction plates, but on
low-velocity gunshot wounds to the mandible, these careful review, we noted that no infections occurred
authors reported a 27% infection rate after open re- when fractures were stabilized using this technique.
duction with wire or external pin fixation. In our Kuriakose et al20 compared rigid internal fixation
review, all patients were treated within the first 36 using 2.7-mm AO/ASIF reconstruction plates with
hours after injury. The relationship between the delay miniplates inserted according to the Michelet–
from the injury to surgical treatment and its affect on Champy principles. A significant difference in the
infection remains controversial. incidence of infection between the 2 plating systems
Stone et al14 performed multivariate analysis and was seen in comminuted fractures, with 30% reported
did not find delay in treatment to be a risk factor for with miniplates and 14.3% with reconstruction plates.
developing infection. Conversely, Prein and Beyer7 With comminuted fractures, the surgeon must per-
stated that “most mandibular fractures that are not form an osteosynthesis capable of supporting full
treated within the first 36 hours must be regarded as functional load and neutralizing tension forces while
infected.” This opinion is shared by other authors,15,16 maintaining fracture fragments in anatomic position.
but at this time no prospective, randomized studies This is impossible to obtain either by closed reduction
can unequivocally state that delayed treatment in- or by use of miniplates according to Champy.21 Using
creases the likelihood of postoperative infection. this latter technique, Potter and Ellis21 reported the
SCOLOZZI AND RICHTER 461

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