Optimization of mandibular fracture treatment
Batbayar, Enkh-Orchlon
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© Enkh-Orchlon Batbayar, 2019
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Printing of this thesis was kindly supported by:
University Medical Center Groningen (UMCG), University of Groningen (RUG) Graduate School Of Medical Sciences, University of Groningen (RUG) KLS Martin, www.klsmartin.com
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fracture treatment
PhD thesis
to obtain the degree of PhD at the
University of Groningen
on the authority of the
Rector Magnificus prof. E. Sterken
and in accordance with
the decision by the College of Deans.
This thesis will be defended in public on
Monday 27 May 2019 at 14.30 hours
by
Enkh-Orchlon Batbayar
born on 23 August 1985
in Ulaanbaatar, Mongolia
Prof. P.U. Dijkstra
Co-supervisor
Dr. B. van Minnen
Assessment Committee
Prof. S.K. Bulstra
Prof. T. Forouzanfar
Prof. J. de Lange
CHAPTER 1 Introduction and aim of the thesis
CHAPTER 2 Non-IMF mandibular fracture reduction techniques: a review of the literature
CHAPTER 3 Accuracy and outcome of manibular fracture reduction without and with aid of repositioning forceps
CHAPTER 4 Development and feasibility of a new reduction forceps for mandibular fractures: a technical innovation
CHAPTER 5 Complications of locking and non-locking plate
systems in mandibular fractures: a systematic review
and meta-analysis
CHAPTER 6 A treatment protocol for fractures of the edentulous mandible
CHAPTER 7 Quantitative 3-dimensional computed tomography measurements provide a precise diagnosis of fractures of the mandibular condylar process.
CHAPTER 8 General discussion CHAPTER 9 Summary
CHAPTER 10 Nederlandse samenvatting (Summary in Dutch) Acknowledgements Appendix Curriculum Vitae 9 21 37 53 63 95 113 135 145 151 157 169 173
INTRODUCTION
Management of mandibular fractures has a long and extensive history. The first known description of mandibular fracture treatment is described 1600 BC in an ancient Egyptian medical text known as the “Edwin Smith Papyrus”1. From this
time till the 19th century, mandibular fractures were mainly immobilized with
head-to-jaw bandages after manual repositioning of the fractures. From the 19th century, the management of mandibular fractures focused on restoration of the occlusion. Simultaneously, management of the fractures shifted from general surgeons to the oral and maxillofacial surgeons. Many intra- and extra-oral splints and circum-mandibular wiring techniques were introduced and modified to immobilize the fractures. For instance, the Gunning splint (by Thomas Gunning), wire ligatures (by Gurnell Hommond), re-introduction of intermaxillary fixation (by Thomas L.Gilmer), Angle’s apparatus (Dr. Angle), and the Ivy loop (Robert H.Ivy) were introduced during the 19th century1. All these
methods were closed treatments of the mandibular fractures. The definition of terms “closed” and “open” treatment of the mandibular fractures has been controversial around the world. According to the consensus article by Bos et al.2 closed treatment is defined as any treatment that does not involve an
open surgical exposure of the fracture whereas open treatment means surgical exposure of the fractures, reduction and fixation2. Closed treatment is still
applied in certain cases of mandibular fractures, particularly for the treatment of incomplete fractures, high condylar fractures, and a selection of non-displaced, immobile fractures.
To achieve uncomplicated fracture healing with open treatment, the following three factors must be considered:
1. Vascularization. The cranio-maxillo-facial region is the most vascularized region of the body, but the mandible is less vascularized than the midface region. The major blood supply of the mandible is provided by the lingual, facial and inferior alveolar arteries.
2. Adequate anatomical reposition (reduction). Reduction of the fractured mandible is crucial to achieve uncomplicated fracture healing. Reduction is the action of reestablishing a fracture by returning the affected segments of the mandible to their normal anatomical position.
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3. Immobilization by means of internal fixation. Open reduction is performed with surgical intervention and it is always followed by immobilization of the fracture. Immobilization has been routinely managed by internal fixation. Stable immobilization leads to primary bone healing without callus formation. Conversely, if immobilization is not rigid enough, the fracture may heal by secondary healing which means that callus formation will occur (Fig 1). Besides these factors, other factors such as the patient’s age, general health, and type of fracture will influence the healing.
Surgical instruments like clamps or forceps have played an important role in the history of traumatology from 1600BC to recent years3. The first known
pivot joint forceps were introduced by Charriere (1845)3,4. Subsequently, this
pivot joint design was modified as a fracture holding forceps, by Faraboeuf and Lambotte3. Since then, all kinds of modifications have been made, and
reduction forceps are routinely used in the modern practice of trauma surgery. The main function of a fracture holding forceps is to secure a firm grasp on the fracture segments in order to get an anatomical reduction of the fracture Fig 1. Schematic drawing of bone healing. A, Primary bone healing with direct bridging of the
without damaging soft tissues and bone allowing comfortable and precise fixation of the fracture. In this manner, fracture fragments can be optimally reduced to enable primary bone healing. The development and use of fracture reduction instruments has mainly been restricted to the field of general trauma surgery and orthopaedic surgery. The role of these instruments in mandibular fracture treatment has been modest. So far no attempt has been made to estimate the benefits and pitfalls of fracture reduction forceps in mandibular fracture treatment. The first goal of this thesis was to review currently available mandibular fracture reduction/alignment methods. This was done with the idea that optimal fixation of a fracture can only be achieved after optimal reposition.
Nowadays, fixation of a mandibular fracture is always achieved by applying one of the available plate and screw systems. In 1886, the German surgeon Hansmann was the first to invent the plate-screw-system for fixation of bone fragments. Much later Luhr5 (1968) introduced the vitallium compression
plate osteosynthesis for mandibular fractures, which had eccentric holes and screws with a conical head while the plates were shaped like a half-pipe surrounding the lower body of the mandible. Since then, numerous plate and screw systems have been introduced and applied for fracture fixation6.
Principally, an osteosynthesis of the mandible can be categorized as ‘load bearing’ or ‘load sharing’. Load bearing plates (also called reconstruction
Fig. 2. A, Regular mini-plate and self-tapping screw. B, Mini-locking-system plate and self-tapping
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plates) are applied when the osteosynthesis system has to withstand all the functional forces at the fracture site. Load-bearing plates are applied in case of complex comminuted fractures, infected fractures, and fractures of a severely atrophic mandible. The dimension of these plates is usually rather coarse. In contrast, the smaller load sharing plates distribute functional forces between plate and bone. Generally, these plates are known as a mini-plates (Fig 2A). As a result of their smaller size they are suitable in cases where, after reduction, interfragmentary stability of the repositioned fragments contributes to the stability of the fracture as a whole. This principle of load sharing fixation only works if the mini-plates are placed in the so-called tension zone. This was made clear during the first attempts to fixate a mandibular fracture with mini-plates. Brons and Boering7, applied small finger plates developed for hand surgery6.
However, they inserted the plates at the lower border of the mandible which was biomechanically unfavorable. Subsequently, Michelet et al. and Champy et al.8,9 developed the mini-plates systems, and contributed enormously to
the understanding of the biomechanical characteristics of the mandible. The Champy’s principle was invented based on the previously introduced surgical device, the mini-plate. It shows that after careful investigation, sometimes it is possible to develop the new surgical techniques by considering surgical instruments.
Another basic concept of osteosynthesis is the locking plate system (Fig 2B). The distinctive feature of the locking plate system is that the screw head itself is threaded and locks firmly into a thread in the plate hole, and so works like an external fixation10–12. The locking plate systems are available
for both load bearing and load sharing plates. Hypothetically, the advantages
Fig 3. Fixation of an apple on a plate. (A) With a locking screw, the assembly is stable. (B) With an
untightened conventional screw, the assembly is unstable. (C) Compression is necessary against the plate, Cronier et al. 201010.
of a locking plate system over a conventional plate system are less screw loosening, greater stability, while less accuracy is required in plate adaption (Fig 3). Although there are many reports in the literature on the outcome of a locking plate system, most are restricted to biomechanical studies, particularly in mandibular fractures13–16. While some clinical studies also tend to favor the
use of a locking plate system in mandibular fractures, other clinical studies did not find a difference with regard to postoperative complications17–21.
Open reduction is facilitated by all instruments and osteosynthesis materials that have been developed in the past century. In addition, the methods for surgical access to the fractures have been improved. A more recent development is the possibility of pre-operative planning of complicated fractures (Fig 4). This development also contributes to anatomical reduction and stable fixation of the fractures.
However, the ultimate goal of the treatment of a fractured mandible is not only to restore the anatomy, but also the function. Although techniques and materials for open reduction have been improved continuously there is still room for closed treatment, especially in cases of fractures of the condylar process. Should these be treated open or closed?
Moreover the management of fractures of the edentulous and severely atrophic mandible is still controversial. It is possible that ongoing discussions on closed versus open treatment a caused by a lack of consensus on the exact Fig. 4. An example of virtual preoperative planning of the atrophic mandibular fracture.
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diagnosis. Recently, three-dimensional analysis of fractures of tibial plateau and acetabular and as well as radial head fractures has been developed for general trauma surgeons, which provide additional information about the fracture extent and quality of the postoperative reduction23–25. The same method
could be applied on mandibular fractures in order to reach an undisputable 3D fracture diagnosis that could help to evaluate treatment outcome. Ultimately this could lead to a better consensus about choices for open and closed treatment.
AIMS OF THE THIS THESIS
Although the outcome of mandibular fracture management is generally satisfactorily there still is room for improvement. The general aim of this thesis was to evaluate fracture reduction/alignment methods including reduction forceps, plate and screw systems, treatment modalities for the edentulous and severely atrophic mandible fractures, and to analyze the condylar process fracture characteristics using three-dimensional methods.
To be more specific:
• to review currently available mandibular fracture reduction/alignment methods (Chapter 2)
• to evaluate fracture reduction/alignment methods and their influence on postoperative complications (Chapter 3)
• to design and develop sophisticated fracture reduction forceps and to test their feasibility (Chapter 4)
• to review the cons and pros of locking and non-locking plate systems (Chapter 5)
• to assess the management of fractures of the edentulous and atrophic mandible (Chapter 6)
• to analyze characteristics of condylar process fractures, based on a three-dimensional analysis (Chapter 7)
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REFERENCES
1. Mukerji R., Mukerji G., McGurk M. Mandibular fractures: Historical perspective. Br J Oral Maxillofac Surg 2006;44(3):222–8. Doi: 10.1016/j.bjoms.2005.06.023. 2. Bos RR., Ward Booth RP., de Bont LG. Mandibular condyle fractures: a consensus.
Br J Oral Maxillofac Surg 1999;37:87–9. Doi: 10.1016/S0266-4356(98)90014-6. 3. Kirkup J. The history and evolution of surgical instruments. X Clamps, haemostats
and related pivot-controlled forceps. Ann R Coll Surg Engl 1999;81(6):420–8. 4. Buraimoh MA., Liu JZ., Sundberg SB., Mott MP. Eponymous Instruments in
Orthopaedic Surgery n.d.;37.
5. Luhr HG. [On the stable osteosynthesis in mandibular fractures]. Dtsch Zahnarztl Z 1968;23(7):754.
6. Sauerbier S., Schön R., Otten JE., Schmelzeisen R., Gutwald R. The development of plate osteosynthesis for the treatment of fractures of the mandibular body - A literature review. J Cranio-Maxillofacial Surg 2008;36(5):251–9. Doi: 10.1016/j. jcms.2007.08.011.
7. Brons R., Boering G. Fractures of the mandibular body treated by stable internal fixation: a preliminary report. J Oral Surg 1970;28(6):407–15.
8. Michelet FX., Deymes J., Dessus B. Osteosynthesis with miniaturized screwed plates in maxillo-facial surgery. J Maxillofac Surg 1973;1(2):79–84.
9. Champy M., Wilk A., Schnebelen JM. [Tretment of mandibular fractures by means of osteosynthesis without intermaxillary immobilization according to F.X. Michelet’s technic]. Zahn Mund Kieferheilkd Zentralbl 1975;63(4):339–41.
10. Cronier P., Pietu G., Dujardin C., Bigorre N., Ducellier F., Gerard R. The concept of locking plates. Orthop Traumatol Surg Res 2010;96(4 SUPPL.). Doi: 10.1016/j. otsr.2010.03.008.
11. Raveh J., Stich H., Sutter F., Greiner R. Use of the titanium-coated hollow screw and reconstruction plate system in bridging of lower jaw defects. J Oral Maxillofac Surg 1984;42(5):281–94.
12. Herford AS., Ellis E. Use of a locking reconstruction bone plate/screw system for mandibular surgery. J Oral Maxillofac Surg 1998;56(11):1261–5.
13. Haim D., Muller A., Leonhardt H., Nowak A., Richter G., Lauer G. Biomechanical study of the Delta plate and the TriLock Delta condyle trauma plate. J Oral Maxillofac Surg 2011;69(10):2619–25. Doi: 10.1016/j.joms.2011.01.002.
14. Haug RH., Street CC., Goltz M. Does plate adaptation affect stability? A biomechanical comparison of locking and nonlocking plates. J Oral Maxillofac Surg 2002;60(11):1319–26.
15. Ribeiro-Junior PDD., Magro-Filho O., Shastri KAA., Papageorge MBB. In vitro evaluation of conventional and locking miniplate/screw systems for the treatment of mandibular angle fractures. Int J Oral Maxillofac Surg 2010;39(11):1109–14. Doi: 10.1016/j.ijom.2010.06.019.
16. Zimmermann C., Henningsen A., Henkel K-O., Klatt J., Jürgens C., Seide K., et al. Biomechanical comparison of a multidirectional locking plate and conventional plates for the osteosynthesis of mandibular angle fractures—A preliminary study. J Cranio-Maxillofacial Surg 2017;45(12):1913–20. Doi: 10.1016/j.jcms.2017.05.020. 17. Collins CP., Pirinjian-Leonard G., Tolas A., Alcalde R. A prospective randomized
clinical trial comparing 2.0-mm locking plates to 2.0-mm standard plates in treatment of mandible fractures. J Oral Maxillofac Surg 2004;62(11):1392–5. Doi: 10.1016/j.joms.2004.04.020.
18. Seemann R., Frerich B., Muller S., Koenke R., Ploder O., Schicho K., et al. Comparison of locking and nonlocking plates in the treatment of mandibular condyle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108(3):328–34. Doi: 10.1016/j.tripleo.2009.04.026.
19. Zhang J., Wang X., Wu R-HR-H., Zhuang Q-WQ-W., Gu QP., Meng J. Comparative evaluation of 2.3 mm locking plate system vs conventional 2.0 mm non locking plate system for mandibular condyle fracture fixation: a seven year retrospective study. Eur Rev Med Pharmacol Sci 2015;19(5):712–8.
20. Yang L., Patil PM. Comparative evaluation of 2.0 mm locking plate system vs 2.0 mm non-locking plate system for mandibular angle fracture fixation: a prospective randomized study. Eur Rev Med Pharmacol Sci 2015;19(4):552–6.
21. Chrcanovic BRR. Locking versus non-locking plate fixation in the management of mandibular fractures: a meta-analysis. Int J Oral Maxillofac Surg 2014;43(10):1243– 50. Doi: 10.1016/j.ijom.2014.07.014.
22. Merema BJ., Kraeima J., ten Duis K., Wendt KW., Warta R., Vos E., et al. The design, production and clinical application of 3D patient-specific implants with drilling guides for acetabular surgery. Injury 2017;48(11):2540–7. Doi: 10.1016/j. injury.2017.08.059.
23. Meesters A. Three-dimensional computed tomography measurements of acetabular fractures Anne Meesters. University of Twente, 2018.
24. Assink N. Quantitative 3-dimensional fracture analysis and patient reported outcomes in patients with intra-articular tibial plateau fractures. University Medical Center Groningen, University of Groningen, 2019.
25. Guitton TG., Werf HJ Van Der., Ring D. Quantitative three-dimensional computed tomography measurement of radial head fractures. J Shoulder Elb Surg 2010;19(7):973–7. Doi: 10.1016/j.jse.2010.03.013.
NON-IMF MANDIBULAR FRACTURE
REDUCTION TECHNIQUES:
A REVIEW OF THE LITERATURE
Enkh-Orchlon Batbayar, Baucke van Minnen, Ruud R.M.Bos J Craniomaxillofac Surg. 2017Aug;45(8):1327-1332.
ABSTRACT
Background. Intermaxillary fixation (IMF) techniques are commonly
used in mandibular fracture treatment to reduce bone fragments and re-establish normal occlusion. However, non-IMF reduction techniques such as repositioning forceps may be preferable due to their quick yet adequate reduction. The purpose of this paper is to assess which non-IMF reduction techniques and reduction forceps are available for fracture reduction in the mandible.
Methods. A systematic search was performed in the databases of Pubmed
and EMBASE. The search was updated until February 2016 and no initial date and language preference was set.
Results. 14 articles were selected for this review, among them ten articles
related to reduction forceps and four articles describing other techniques. Thus, modification and design of reduction forceps and other reduction techniques are qualitatively described.
Conclusion. Few designs of repositioning forceps have been proposed in the
literature. Quick and adequate reduction of fractures seems possible with non-IMF techniques resulting in anatomic repositioning and shorter operation time, especially in cases with good interfragmentary stability. Further development and clinical testing of reduction forceps is necessary to establish their future role in maxillofacial fracture treatment.
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INTRODUCTION
Mandibular fractures are the most common injuries of the maxillo-facial area.1
Reduction of the fractured bone segments is an important phase of fracture treatment of any bone, as precise reduction facilitates the bone healing process and reduces infections.2,3Direct bone contact between the fracture segments
supports primary bone healing, which leads to earlier bone regrowth and stability across the fracture site. However, reduction gaps of more than 1 mm across fractured bone segments result in secondary healing, which causes callus formation and increases the risk of a malunion.4
Reduction of mandibular fractures is achieved by using intermaxillary fixation (either with IMF screws or splints), reduction forceps, manual reduction, or a combination of these methods. The choice of method depends on the location and severity of the trauma, preference of the surgeon, and the dislocation or comminution. The application of IMF with arch bars is time-consuming, and has several disadvantages, such as patient discomfort, gingivitis and infection. Recently, IMF screws have become more popular in mandibular trauma surgery due to their easy and quick application. However, screw failure, gingival and mucosal tissue damage and root injury may occur.5 In order to overcome
the possible disadvantages of IMF techniques, some surgeons prefer to use manual repositioning or reduction forceps. Several studies have shown that reduction forceps could significantly reduce operation time, and their use results in adequate bone fragment reduction and causes few postoperative complications such as infection and occlusal disturbance.3,6,7 However,
surgeons must pay attention to lingual site gapping when using reduction forceps, because it could cause separation of lingual borders of the mandible. According to the literature, only a few types of repositioning forceps are available for application in OMF surgery. Frequently, modified larger towel clamps are used,6,8 but some surgeons and biomedical engineers have reported on the
development of more efficient ones.7,9,10 The aim of this paper is to review all
studies related to reduction forceps and other non-IMF reduction techniques in order to assess which forceps are available and which developments are needed.
MATERIALS AND METHODS
In order to identify studies on reduction forceps for mandibular fractures, a systematic search was performed in the database of PUBMED and EMBASE. The search was updated until February, 2016 and no initial date and language preferences were set. Furthermore, citations of the retrieved articles were screened to identify additional relevant articles. Case reports, studies on small populations, technical notes and laboratory studies were all included in this review.
Pubmed search: (“Mandibular Fractures”[Mesh] OR (mandibula* AND
fracture*)) AND (“Fracture Fixation, Internal”[Mesh] OR “Jaw Fixation Techniques”[Mesh] OR fixation*) AND (reduction* OR clamp* OR “forceps”) Embase search: ‘mandible fracture’/exp AND ‘fracture reduction’/exp OR ‘reduction forceps’ OR ‘reduction clamps’
RESULTS
The systematic search strategy resulted in 1285 hits from the Pubmed and Embase, of which 295 duplicates were removed. The titles of the remaining 990 articles were screened, after which another 925 hits were ejected due to irrelevancy. The abstracts of the remaining 65 articles were screened, and another 52 publications were excluded as they were not relevant or animal studies. Screening of the references resulted in one additional publication. Finally, 14 articles were chosen for this review (Fig 1). The selected articles were categorized as either clinical or experimental studies.
1. Clinical studies
Accuracy of fracture reduction
Eight of the 14 articles mentioned that stable pre-compression and reduction were achieved with help of a reduction forceps. Four articles described other techniques which will be described below.
Reduction forceps. In one study6, two modified reduction forceps were used
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inferior border and another one in the subapical zone of the anterior mandible, in order to reduce lingual cortical bone sufficiently. In the other clinical studies, the reduction was achieved by using one clamp or forceps in the anterior and posterior region of the mandible.
The success of the reduction is described in terms of postoperative clinical observation and complications in all eight articles. Two studies described additional post-reduction radiography to confirm healing. Mandibular angle fracture cases were followed up prospectively via orthopantomograms (OPG) and reverse Towne views or both.3,7 The study of Choi et al.3 included two
treatment groups (reduction forceps and IMF group) and used a scale of 1 to 3 to assess the accuracy of anatomic reduction in the radiographic image. A score of 1 indicated a poorly reduced fracture which required a second operation, while a score of 2 indicated a slight displacement but an acceptable occlusion. A score of 3 indicated a precise reduction. The reduction forceps group had a higher number of accurate anatomic alignments of the fractures than the IMF group.
Three studies provided information about the distance between the drill holes in which the teeth of the forceps find their grip. One study11 describes two
monocortical holes were drilled, each 10 mm from the fracture line. A second study12 describes monocortical holes at approximately 12 mm from the fracture
line at midway down the vertical height of the mandible. The third study describes either monocortical or bicortical holes depending on difficulties. These difficulties are not described in detail. In this study8, the distance of 5-8
mm from the fracture was chosen at the inferior margin of the mandible (Table 1).
Other techniques. Scafati et al.13 used elastic rubber bands stretched between
screws placed across both sides of the fractured parts in order to reduce mandibular and orbito-maxillary fractures. Orthodontic rubber bands and two self-tapping monocortical titanium screws with 2 mm diameter and 9-13 mm length were used. The heads of the screws protruded about 5 mm and the axis had to be perpendicular to the fracture line. Degala et al.14 used comparable
techniques for symphyseal, parasymphyseal and body fractures. Titanium screws with 2 mm diameter and 8 mm length were tightened at a distance of 10-20 mm from the line of fracture, and around 2 mm screw length remained above the bone to engage a 24 G wire loop. However, before applying this technique, they used IMF.
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Table.1 General description of the studies Study Study type No. of
patients Fracture location Type of reduction method Drill holes distance (from the fracture line)
Kallela et
al.17 Clinical/ retrospective 23 Angle, Parasymphyseal Shortened peaks forceps with IMF and
lag-screw
At apical level
Žerdoner
et al.11 Clinical 60 Angle Symphyseal
Parasymphyseal
Self-cutting screw with reposition forceps catching the screws
10 mm
Rogers et
al.8 Clinical/ Ideas and
innovations
100 Angle Symphyseal Parasymphyseal
Modified large towel
clamp 5-8 mm at inferior margin of mandible
Choi et al.9 Clinical/ Technical
note
Angle Specifically designed forceps of the angle fractures -
Choi et
al.3 Clinical/ Retrospectiv
e
46 Angle
Intraoral Same with above -
Shinohar
a et al.6 Clinical/ Case report 2 Symphyseal Parasymphyseal
Intraoral
Modified reduction forceps -
Kluszyns
ki et al.12 Clinical/ Case report 4 Body Symphyseal
Parasymphyseal
Right angled reduction
forceps 12 mm at midway level
Scolozzi
et al.7 Clinical/ Case report 7 Transverse angle Specifically designed with 70 degree angle in
tips -
Scafati et
al.13 Clinical/ Technical
note 104 Symphyseal Parasymphyseal Body, Angle, Ramus Orbito-maxillary complex fractures
Elastic internal traction 5-20 mm
Degala et
al.14 Clinical/ Technical
note
80 Body Symphyseal Parasymphyseal
Tension band wiring 10-20 mm
El-Gengehi et al.16
Clinical/
Clinical study 24 Body Angle Computer guided fracture reduction with custom-fabricated surgical stent
-
Beech et
al.15 Clinical/ Technical
note
1 Bilateral (Right angle, left parasymphyseal)
Vacuum-formed splint -
Choi et
al.18 Experimental 36* Body Symphyseal
Parasymphyseal
Stress patterns
generated by Synthes 10-16 mm in the 3 reduction forceps model
398.98 different level
Kontio10 Experimental - Only virtual reduction in
a computer model with computer aided designed forceps
-
Two publications describe reduction methods that use custom made splints. A vacuum-formed splint was used by Beech et al.15 in the reduction of one
bilateral mandibular fracture case. In this case, the patient underwent two operations. Final precise reduction and fixation was done seven days after immediate stabilization with miniplates and screws followed by alginate impressions for manufacturing the splint. El-Gengehi et al.16 virtually reduced
mandibular fracture segments based on three-dimensional reconstruction of a CBCT scan. Based on the reconstruction, custom made surgical guides were fabricated. At the start of the surgical treatment, the mandibular fracture segments were aligned with help of the custom made a surgical guide, which was placed in the subapical zone using monocortical mini screws. Above and below this guide the osteosynthesis material was placed to fixate the fracture. Finally the guide was removed.
Postoperative complications
Several authors6,8,11 did not mention post-operative complications, whereas
other authors7,12 did not experience any complications when they used
reduction forceps. Kallela et al.17 described some cases with infection and
non-stable fixation. However, in this study, they used a lag screw technique for fixation instead of plates and screws. Choi et al.3 noted one case of infection in
the reduction forceps group versus four cases in the IMF group. The IMF group had two cases with occlusal disturbance, while no occlusal disturbance was observed in the reduction forceps group. Furthermore, one case of dental root perforation due to the IMF screw and two cases of infections with malunion were observed in the elastic internal traction technique group.13 In a study on
the tension band wiring technique14 three cases developed an infection and
eight cases had a minor occlusal discrepancy. Duration of surgery
Two studies reported on the duration of the operation when using reduction forceps. Shinohara et al.6 mentioned that using reduction forceps without IMF
for mandibular fractures reduced the time of surgery, but they did not provide exact information on operation times. Choi et al.3 described operation times
as being significantly reduced in the reduction forceps group; the average operation time was 41 minutes in the forceps group compared to 87 minutes in IMF group. With respect to other techniques, operative time was shortened in several studies13,14 but the authors did not provide exact information either.
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2. Design of the repositioning forceps
Eight articles described a new design for reposition forceps.3,6–9,11,12,17 These
designs can be divided into two groups. A. Modified towel clamps
A standard towel clamp was modified by Rogers et al.8 bending two ends
of a clamp approximately 10 degrees outward. This was done to prevent disengagement from the bone (Fig 2-A). Kellela et al.17 modified a standard
AO reduction forceps through shortening the teeth and made notches at the ends to grasp tightly in the drill holes (Fig 2B). Shinohara et al.6 used two
modified reduction forceps: one was positioned at the inferior border and the other in the neutral subapical zone. However, the authors did not describe the modification technique (Fig 2C).
Fig 2. Schematic drawing of existing reduction forceps. A, Modified towel-clamp (Rogers et al.) B,
Modified AO forceps (Kellela et al.) C, Modified reduction forceps (Shinohora et al.) D, Reduction forceps for mandibular angle fracture (Choi et al.), E, Commercially available reduction forceps (Synthes).
B. Specific or new design
New reduction forceps were developed by Choi et al.3,9 for mandibular angle
fractures based on the unique anatomy of the oblique line and body; one end of the forceps was designed for positioning in the fragment medial to the oblique line and another end was positioned in the distal fragment below the oblique line. The prongs are asymmetrically designed, with the medial prong being longer than the distal one (Fig 2D).
The reduction-compression forceps of Scolozzi et al.7 was designed similar to
standard orthopedic atraumatic grasping forceps (Fig 3A).
Kluszynski et al.12 designed a prototype of a right-angled reduction forceps to
prevent bone chipping of the drill holes during the reduction (Fig 3B).
Fig 3. Schematic drawing of existing reduction forceps (continues) A, Specific ad hoc, the prongs
of the forceps made a 90-degree angle sagittally and a 70-degree angle coronally relative to the midline of the forceps (Scolozzi et al.) B, Right-angle, prongs are designed an approximately 90-degree angle coronally (Kluszynski et al.) C, Combination of self-cutting screws and a repositioning forceps (Zerdoner et al.).
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Žerdoner et al.11 used a combination of self-cutting screws and a repositioning
forceps which has butterfly-like shaped prongs. First, two screws are fastened on each side of the fracture line and then the reposition forceps is placed over the heads of the screws (Fig 3C).
3. Experimental studies
Choi et al. 18 evaluated the stress pattern generated by reduction forceps
(Fig 2E; Model 398.98 Synthes, Waldenberg, Switzerland) with a photoelastic mandibular model in order to determine the ideal position of the reduction forceps. They osteotomized 36 mandibular models into three groups of fractures: symphyseal, parasymphyseal and body fractures. According to this study, symphyseal and parasymphyseal fractures have similar stress distributions, and a distance between the two engagement holes of more than 12 mm is ideal in both lingual and labial areas. Furthermore, reduction forceps should be placed between the midway level of the mandible or 5 mm below the midway level. In the case of body fractures, optimum stress distribution was achieved when both tips of a reduction forceps were placed more than 16 mm away from the fracture line at midway level.
Virtually designed reduction forceps were developed using a parametric computer aided design (CAD) and additive manufacturing (AM) for the prototype.10 In this study, the instruments consist of three separate units:
handle, jaw and bar. The prongs of this forceps hold the bone fragments rigidly and the oval axial line of the handles was designed to retract the buccal soft tissues and muscles. However, due to several design-related complications they were unable to make a prototype.
DISCUSSION
The use of reduction forceps has been known for many years in general trauma surgery, orthopedic surgery and plastic surgery. In OMF surgery traditionally the dental occlusion was used to perform and check reduction of mandibular fractures. Notwithstanding this historical background, reduction forceps can be used in mandibular fractures as in any other fracture as long as there is sufficient space and as long as the fracture surface permits stable placement and withstands the forces created by such a forceps. Although there have been a number of publications presenting various designs of reduction forceps for use in OMF surgery, a review never has been published.
This article describes the advantages and weak points of the various reduction forceps and their clinical use and designs.
Each author almost exclusively uses his own type of forceps, although there are similarities in the designs. Generally, the curvature in the design of the prongs of any kind of grasping instruments such as bone forceps or towel clamps were kept in all models described in this review, except for a right-angle forceps (Fig.3B). Most of the authors6,8,17 simply bent the prongs of the forceps
into different angles in order to improve their grip and the pre-compression during the reduction. Mandibular symphyseal and parasymphyseal fractures were rather easy to reduce with reduction forceps due to their curved shape. However, mandibular angle fractures are more challenging to reduce due to the difficulty of positioning the forceps intraorally. Therefore, a specific reduction forceps was designed3,9 for fractures of this area. However, this forceps was
not able to reduce oblique fractures of the mandible. The modified towel clamp by Rogers et al.8 could be used in angle fracture via an extraoral incision, but
this clamp is less effective in oblique fractures as well. Therefore, it would be desirable to develop a universal forceps design for all types of mandibular angle fractures.
The positioning of the forceps and location of drill holes are important for adequate reduction and compression. Clinical studies have suggested that a distance of the holes of at least 8-12mm (average 10mm) from the fracture line allows better reduction and pre-compression. Therefore, new designs for the reduction forceps need a certain freedom of movement to allow them to function when holes are at 8-16 mm from the fracture line, and also it should be able to lock fully. Applying reduction forceps can make IMF unnecessary and so reduces operation time. Additionally, with respect to the patient, IMF-related complications such as gingivitis, pain, discomfort or difficulties in maintaining oral hygiene and root injury by IMF screws are diminished by avoiding IMF. Treating patients without IMF could reduce the risk of injury or infection of the surgeons and nursing staff and decreases the number of assistants as well. Other fracture reduction methods such as traction wire or elastic tension on screws are simple to use in the area of anterior mandibular fractures, but not in the posterior part of the mandible. In addition, this method may cause a gap at the lingual side of the fracture as an effect of the resultant of the force exerted on the protruding screws. This lingual gap should be prevented with reduction forceps as they grab inside the bone and are positioned at a distance of the
2
fractures site of at least 8-10 mm this should prevented.8,11,12 Choi et al.18
even suggested that tips of repositioning forceps should place at least 12mm from each site of the fracture line in case of symphyseal and parasympheseal fractures. In the mandibular body fractures, adequate stress pattern at the lingual site was found at least 16 mm from fracture line.
CONCLUSION
Based on this review it can be concluded that only a few designs of repositioning forceps have been proposed in the literature. Quick and adequate reduction of fractures seems possible with this technique resulting in anatomic repositioning and shorter operation time, especially in cases with good interfragmentary stability. A satisfying solution for the posterior part of the mandible is not yet available. Further development and clinical testing of reduction forceps is necessary to establish their future role in maxillofacial fracture treatment. Better reduction and decreasing of operation time are incentives to explore the possibilities.
ACKNOWLEDGEMENTS
The authors would like to thank Otgongerel Nyamsambuu, for drawing the forceps.
REFERENCES
1. Gassner R., Tuli T., Hächl O., Rudisch A., Ulmer H. Cranio-maxillofacial trauma: A 10 year review of 9543 cases with 21 067 injuries. J Cranio-Maxillofacial Surg 2003;31(1):51–61. Doi: 10.1016/S1010-5182(02)00168-3.
2. Perren SM., Huggler A., Russenberger M., Straumann F., M¨ller ME., Allgöwer M. A Method of Measuring the Change in Compression Applied to Living Cortical Bone. Acta Orthop Scand 1969;40(sup125):1–63. Doi: 10.3109/ort.1969.40.suppl-125.01. 3. Choi BH., Kim HJ., Kim MK., Han SG., Huh JY., Kim BY., et al. Management of
mandibular angle fractures using the mandibular angle reduction forceps. Int J Oral Maxillofac Surg 2005;34(3):257–61. Doi: 10.1016/j.ijom.2004.05.009.
4. Schmoker R., Von Allmen G., Tschopp HM. Application of functionally stable fixation in maxillofacial surgery according to the ASIF principles. J Oral Maxillofac Surg 1982;40(7):457–61.
5. Van Den Bergh B., Blankestijn J., Van Der Ploeg T., Tuinzing DB., Forouzanfar T. Conservative treatment of a mandibular condyle fracture: Comparing intermaxillary fixation with screws or arch bar. A randomised clinical trial. J Cranio-Maxillofacial Surg 2015;43(5):671–6. Doi: 10.1016/j.jcms.2015.03.010.
6. Shinohara EH., Mitsuda ST., Miyagusko JM., Horikawa FK. Mandibular fracture reduction without intraoperative intermaxillary fixation: A technique using two modified reduction forceps. J Contemp Dent Pract 2006;7(1):150–6.
7. Scolozzi P., Jaques B. Intraoral open reduction and internal fixation of displaced mandibular angle fractures using a specific ad hoc reduction-compression forceps: a preliminary study. Oral Surgery, Oral Med Oral Pathol Oral Radiol Endodontology 2008;106(4):497–501. Doi: 10.1016/j.tripleo.2008.01.018.
8. Rogers GF., Sargent L a. Modified towel-clamp technique to effect reduction of displaced mandible fractures. Plast Reconstr Surg 2000;105(2):695–7. Doi: 10.1097/00006534-200002000-00033.
9. Choi BH., Suh CH., Par JH., Yoo JH., Kim HJ. An effective technique for open reduction of mandibular angle fractures using new reduction forceps: technical innovations. Int J Oral Maxillofac Surg 2001;30(6):555–7. Doi: 10.1054/ ijom.2001.0158.
10. Kontio R. Designing and Additive Manufacturing A Prototype for A Novel Instrument for Mandible Fracture Reduction. Surg Curr Res 2013;03(01):2–4. Doi: 10.4172/2161-1076.S1-002.
11. Žerdoner D., Žajdela Z. Reposition forceps for osteosynthesis by means of miniplates. Br J Oral Maxillofac Surg 1998;36(5):392–3. Doi: 10.1016/S0266-4356(98)90654-4.
12. Kluszynski BA., Wineland AM., Kokoska MS. Mechanical and clinical rationale of prototype bone reduction forceps. Arch Facial Plast Surg 2007;9(2):106–9. Doi: 10.1001/archfaci.9.2.106.
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effective method to reduce the displaced facial fractures. Int J Oral Maxillofac Surg 2004;33(7):709–12. Doi: 10.1016/j.ijom.2004.02.008.
14. Degala S., Gupta N. “Tension Band Wiring” A Simplified Approach for Fracture Reduction and Intermittent Stabilization. J Maxillofac Oral Surg 2010;9(4):382–4. Doi: 10.1007/s12663-010-0111-y.
15. Beech AN., Farrier JN. Technical note Operative use of a vacuum-formed splint in the reduction of displaced mandibular fractures. Br J Oral Maxillofac Surg 2016;54(2):224–5. Doi: 10.1016/j.bjoms.2015.12.018.
16. el-Gengehi M., Seif S a. Evaluation of the Accuracy of Computer-Guided Mandibular Fracture Reduction. J Craniofac Surg 2015;26(5):1587–91. Doi: 10.1097/SCS.0000000000001773.
17. Kallela I., Ilzuka T., Laine P., Lindqvist C. Lag-screw fixation of mandibular parasymphyseal and angle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82(5):510–6.
18. Choi BH., Park JH., Yoo TM., Huh JY., Suh CH. Evaluation of stress patterns generated by reduction forceps within a photoelastic mandibular model. J Cranio-Maxillofacial Surg 2003;31(2):120–5. Doi: 10.1016/S1010-5182(02)00185-3.
ACCURACY AND OUTCOME OF
MANDIBULAR FRACTURE REDUCTION
WITHOUT AND WITH AID OF A
REPOSITIONING FORCEPS
Enkh-Orchlon Batbayar, Somaia Malwand, Pieter U. Dijkstra, Ruud R.M. Bos, Baucke van Minnen
Accepted version of:
Oral Maxillofac Surg. (2019) DOI: 10.1007/s10006-019-00759-0
ABSTRACT
Purpose. It is presumed that adequate reduction of a fracture of the
mandible favors bone healing and diminishes the risk of complications. In this retrospective study, we compared the accuracy of fracture alignment and complication rate of mandibular fractures reduced without or with aid of a
repositioning forceps.
Methods. Retrospective analysis of consecutive 252 patients with mandibular
fractures treated between January 2010 and December 2016. Eligible for this study were patients with isolated mandibular fractures needing open reduction and internal fixation in whom pre- and postoperative radiographs and patient records were available. In total 131 (252 fractures) patients fulfilled the inclusion criteria.
Results. Seventy-one (54%) patients were men. Mean age of the patients was
33±16.5 years and the median and interquartile range of age was 25 (20;41). In 54 patients’ mandibular fractures were reduced without the aid of repositioning forceps, in the remaining 77 patients the fractures were reduced with the aid of the repositioning forceps. Anatomical alignment of the fractures was poor in the non-forceps aided group (48%) compared to the forceps-aided group (58%) (P=.067). Overall complication rate was higher in the group of fractures reduced without the aid of forceps (17%) than in the forceps-aided group (7%) ( P=.045; OR, 2.7; 95% CI, 1.0-7.4).
Conclusions. Mandibular fractures reduced with the aid of repositioning
forceps are accompanied by a lower complication rate and better alignment. This is an important observation as better alignment of the fracture fragments favors bone healing and reduces complications.
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INTRODUCTION
Mandibular fracture treatment aims to achieve adequate reduction of the fracture fragments, to immobilize these fragments firmly in order to restore premorbid occlusion, and to promote direct bone healing. Common methods for reduction of mandibular fractures include intermaxillary fixation (IMF), manual reduction and the use of a repositioning forceps. After adequate reduction, the aligned fragments are fixated with osteosynthesis materials.
IMF is used primarily to restore occlusion and secondarily to reduce the fracture1,2. Commonly, IMF is applied by wiring the upper and lower jaws
with the arch bars, but there is a variety of alternative techniques including IMF screws. Although shown to be successful, the various IMF techniques have drawbacks including an increased risk of root injury, IMF screw failure, accidental needle stick injury and discomfort to the patient3–5. The use of
IMF is not a prerequisite to reduce and fixate mandibular fractures6,7, manual
reduction and use of repositioning forceps are reliable alternatives2,8–13. When
performing manual reduction, extra hands to reduce the fracture fragments are needed, preferably with aid of a skilled assistant3. Moreover, there is not always
sufficient room to insert osteosynthesis materials via intraoral approach due to the limited access to the fracture when manually aligning fracture fragments. With a repositioning forceps, a more accurate anatomical reduction and higher pre-compression can be achieved compared to IMF or manual reduction2.
This better alignment of the fragments is presumed to favor bone healing and diminish risks of complications.
All above-mentioned mandibular fracture reduction techniques are viable options for treatment of mandibular fractures. In clinical practice, these techniques are often used in combination with each other. The objective of the current study was to analyze the added value of using repositioning forceps in the mandibular fracture treatment. We hypothesize that mandibular fracture treatment, when a repositioning forceps is used, will result in a more accurate fracture alignment and less postoperative complications.
MATERIALS AND METHODS
Study population
The medical records of all patients who received surgical treatment for mandibular fractures between January 2010 and December 2016 at the Department of Oral and Maxillofacial Surgery, University Medical Centre Groningen, the Netherlands were assessed for eligibility. Inclusion criteria were isolated mandibular fractures that required treatment with open reduction and internal fixation (ORIF) and availability of pre- and postoperative radiographs and records. Both unilateral single/double fracture(s) and bilateral fractures of the mandible were included. Exclusion criteria were closed treatment of a mandibular fracture, bi-maxillary fractures, inadequate radiographs, and fractures older than 3 weeks at the time of treatment.
Fracture reduction techniques and surgery
Reduction of mandibular fractures was achieved by either manual reduction, IMF, the use of repositioning forceps or a combination of these techniques(Fig
1). The reduction techniques were grouped as follows: (1) fractures reduced
without the aid of repositioning forceps, and (2) fracture reduced with the aid of repositioning forceps. All operations were performed under general anesthesia by an oral and maxillofacial surgeon assisted by residents. The choice of the reduction methods applied was based on the case complexity and the surgeon’s preference.
Study variables and outcome measurements
Age, gender, cause of trauma, comorbidity, occlusal state, oral hygiene, smoking habits, dental status, fracture type, fracture location and type, the order in which IMF, manual reduction and/or the use of a reduction forceps were used, fracture fixation method, postoperative fracture alignment and complications were extracted from the patient records. Postoperative fracture alignment was evaluated by two observers based on postoperative radiographs along with the clinical appraisal of occlusion according to the following score: (1) poor reduction of the fracture needing reoperation, (2) fracture was reduced with slight dislocation, but clinically with a satisfying occlusion, and (3) reduction of the fracture with anatomic alignment. The reported complications were
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Fig 1. Illustrative explanation of the fracture reduction techniques: A-Manual reduction,
B-Repositioning forceps, C-IMF with arch bar and wire, and D-IMF screw and wire. The repositioning forceps aided group includes “B” alone; or “B” combination with (and/or) “A”, “C”, and ”D”. The non-forceps aided group includes “A”, “C”, and ”D” alone; or combination of those.
divided into complications needing reoperation (major) and complications not needing surgical intervention (minor). The immediate postoperative occlusion was assessed by oral and maxillofacial surgeons of the department by clinical examnation and assessing the patients’s experience of occlusal disturbance.
Statistical analysis
We performed two groups of statistical analyses, one with the patient as unit of analysis, and one with the fracture as unit of analysis. Age, gender, cause of trauma, comorbidity, occlusal state, oral hygiene, smoking habits, dental status, fracture type and complications were analyzed per patient. Fracture location and type, fracture fixation method, postoperative fracture alignment, and complications were analyzed per fracture. When unit of analysis was fracture, possible concomitant condylar or ramus fractures were excluded from the comparison of reduction methods regarding complications, if the concomitant fractures were treated closed. In another words, the comparison was made only with fractures that underwent open reduction and internal fixation (ORIF).
Chi-square (Exact test when actual or expected cell filling was not too low), t-test, Mann-Whitney U and logistic regression analysis were applied to analyze differences between reduction techniques regarding reduction accuracy (alignment), patient and fracture characteristic, and postoperative complications.
To identify possible confounding factors, we explored associations between complications (no, yes) and the following variables: age, gender (male, female), co-morbidity (no, yes), smoking (no, yes), oral hygiene (good, poor), velocity of trauma (high, low), mandible fracture(s) concomitant with condyle (no, yes), fracture reduction techniques (with the aid of forceps, without the aid of forceps), fracture location, and fracture fixation methods (load sharing, load bearing or combination). Statistical significance was set at p≤ .05 and consistently evaluated using 2-sided tests. Data were analyzed with IBM SPSS version 23.0.03 software.
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RESULTS
General characteristics of patients
Of the 203 patients with mandibular fractures that were treated between January 2010 and December 2016, 131 patients with 252 fractures met the inclusion criteria (Fig 2). The mean age of the patients was 33±16.5, the median (interquartile range (IQR)) of age was 25 (20;41), and 103 patients (79%) were male. The median (IQR) number of fractures per patients was 2 (1; 2). Three patients had cardiovascular disease, three patients had diabetes (type II), two patients had alcohol abuse and one patient had a psychological problem. Eighty-two (63%) out of the 131 eligible patients were fully dentate, 38 (29%) were partially dentate and 11 (8%) patients were edentulous. Eighteen (14%) patients were smokers. Oral hygiene status was not recorded in 11 (8%)
Table 1. Patients characteristics and reduction techniques (unit of analysis: patients, n=131) Reduction not aided by the forceps (n=54) a Reduction aided by the forceps (n=77) a P valuec Age (mean ± SD) 33.0±16.4 32.9±16.7 .687* Number of fractures (mean ± SD) 1.9±.7 1.8±.7 .186* Gender (n=131) Male 43 (80) 60 (78) .496 Female 11 (20) 17 (22) Smoking (n=131) No 49 (91) 64 (83) .161 Yes 5 (9) 13 (17) Oral hygiene (n=120) Good Poor 44 (92) 4 (8) 66 (92) 6 (8) .638 Co-morbidity (n=131) No Yes 45 (83) 9 (17) 73 (95) 4 (5) .039 Dental status (n=131) Complete Partially 37 (69) 11 (20) 45 (58) 27 (35) .156 Edentulous 6 (11) 5 (7) Fracture type
(n=131) Single fracture Single fracture 19 (35 ) 17 (22) .432 concomitant condyle (unilateral or bilateral) 14 (26) 24 (31) Bilateral or unilateral double fracture 19 (35) 32 (42) Bilateral fracture concomitant condyle (unilateral or bilateral)) 2 (4) 4 (5) Complication No 39 (72) 71 (92) .005 Minor 10 (19) 3 (4) Major 5 (9) 3 (4) a Column percentage
b Number of valid data (Fractures treated with closed treatment excluded, no reduction was needed) c Chi square test
* Mann-Whitney U test
edentulous patients. In 110 (92%) patients’ oral hygiene was good, and 10 (8%) patients had poor oral hygiene. The cause of the mandibular fractures was assault (n=45, 34%), fall (n=27, 21%), motor vehicle accident (n=25, 19%), bicycle accident (n=25, 19%), sports injury (n=7, 5%), and accident at home (n=2, 2%).
The fractures occurred in the mandibular (para)symphyseal region (n=67, 27%), body (n=54, 21%), angle (n=47, 19%), ramus (n=23, 9%) and condyle (n=61, 24%). Among the 252 fractures, 206 (82%) fractures were simple, 37 (14%) comminuted and 9 (4%) incomplete. The simple fractures were more frequently observed in the (para)symphyseal (n=53, 26%), angle (n=42, 21%), and condyle or ramus (n=75, 36%) region of the mandible, and less in the body region (n=36, 17%). The comminuted fractures were mainly observed in the
3
(para)symphyseal (n=14, 38%) and body (n=18, 48%) region followed by angle (n=4, 11%) and condyle (n=1, 3%) region.
Patient characteristics and reduction techniques
In 54 patients the fractures were reduced without the aid of a repositioning forceps, and in 77 (66%) patients the fractures were reduced with the aid of the forceps. The two groups were similar with regard to age of the patients and number of mandibular fractures per patients (Table 1). Co-morbidity was observed more often in the non-forceps aided group (P=.04; OR=3.6, 95% CI, 1-12).
Of the minor complications observed (Table 1) in the non-forceps aid group, soft tissue infection was found in 6 patients (11%), periapical radiolucency due to IMF screw in 1 patient (2%), asymptomatic plate fracture in 1 patient (2%), and poor occlusal need elastic traction in 2 patients (4%). In the forceps-aided group, soft tissue infection was found in 1 patient (1%), and asymptomatic plate fracture in 2 patients (3%).
Table 2. Fracture characteristics and reduction techniques (unit of analysis: fracture, n=252) Variables
Open treatment and internal
fixation (n=179) Closed (n=73) P value
c Reduction not aided by the forceps (n=90) a Reduction aided by forceps (n=89) a No reduction (n=73) a Fracture locations (n=252) (Para)Symphysesal 16 (18) 51 (57) 0 .001 Body 26 (29) 28 (32) 0 Angle 37 (41) 10 (11) 0 Ramus 2 (2) 0 21(29) Condyle 9 (10) 0 52 (71) Fracture type (n=252) Simple Comminuted 74 (82) 16 (18) 69 (78) 20 (22) 64 (87) 1 (2) .001 Incomplete 0 0 8 (11) Fracture fixation (n=178)b Load sharing 82 (91) 76 (85) .466 Load bearing 2 (2) 4 (5) Both 6 (7) 9 (10) Complications (n=252) No Yes 75 (83) 15 (17) 83 (93) 6 (7) 73 (100) 0 .001 a Column percentage
b Number of valid data (Fractures treated with closed treatment excluded due to no reduction was done) c Chi square test
Fig 3. Bar chart comparing the postoperative fracture alignment score by reduction techniques. A
score 1- poorly reduced fracture needing reoperation, a score 2- reduced with slight dislocation, but clinically satisficing occlusion, a score 3- reduced with anatomic alignment (*Result of Mann-Whitney U).
Of the major complications observed (Table 1) in the non-forceps aided group, insufficient reduction occurred in 4 patients (7%), and lingual flaring in 1 patient (2%). In the forceps-aided group, non-union in 1 patient (1%), and lingual flaring in 2 patients (3%). The overall complication rate was significantly higher in the non-forceps aided group (P=.004; OR=4.5, 95% CI, 1.6-12.6).
Fracture characteristics and reduction techniques
Of the 252 fractures, a total of 179 (71%) primary fractures was treated by ORIF, and 73 (29%) concomitant fractures were treated closed (no reduction was needed). The forceps-aided fracture reduction was applied less often in the angle region than in the (para)symphysesal and the body region of the mandible (Table 2). Both simple and comminuted mandibular fractures were as often reduced with and without the aid of forceps. Internal fixation of the fractures was achieved with similar osteosynthesis methods in both groups. Fracture alignment tended to be better for the fractures reduced with the aid of repositioning forceps (Fig 3).
In the non-forceps aided group, 15 (17%) fractures had complications (minor n=10, 11%; major n=5, 6%), and in the forceps-aided group, 6 (7%) fractures had complications (minor n=3, 3.5%; major n=3, 3.5%). Detailed complications
3
Tab le 3. Com pl ic at ions a ss oc ia te d w ith fra ct ure lo ca tion of e ac h grou p (n =252 fr ac tur es ) C omp lic ati on s O pe n t re atm en t an d i nte rn al fi xati on (n =1 79) C los ed (n =73) Re du ct ion not a ide d by the for ce ps (n= 90) Re du ct ion ai de d by for ce ps (n= 89) No re duc tion (n= 73 ) (P ara ) sym phys ea l Body A ngl e Ra m us Condyl e (P ara ) sym phys ea l Body A ngl e Ra m us Condyl e Ra m us Condyl e No 13 (82 ) 20 (77) 31 (83) 2 (100) 9 (100 ) 50 (98 ) 27(96) 6 (60) 0 0 0 0 M inor Infe ct io ns 0 3 (11) 3 (8) 0 0 0 0 1 (10) Poor occ lu sio n n eed s e las tic tra ct ion 1 (6) 1 (4) 0 0 0 0 0 0 0 0 1* 3* A sym pt om at ic p la te fr ac ture 0 0 1 (3) 0 0 0 0 2 (20) 0 0 0 0 Pe ria pi ca l r ad io lu ce nc y d ue to IMF sc re w 0 0 1 (3) 0 0 0 0 0 0 0 0 0 M aj or Ins uffi ci ent re duc tion 1 (6) 2 (8) 1 (3) 0 0 0 0 0 0 0 0 0 Lin gu al flar in g 1 (6) 0 0 0 0 1 (2) 1 (4) 0 0 0 0 0 No n-uni on 0 0 0 0 0 0 0 1 (10) 0 0 0 0 *E xp ec te d c los ed tr ea tm en t r es ul t w ith a for es ee n corr ec tion for conc om ita nt (c ondyl ar a nd ra m us ) fr ac ture sTable 4. Binary logistic regression analysis: Calculation of odds of having postoperative complications OR (CI 95%) P value
Unit of analysis number of patients
Age 1.0 (0.9-1.0) .927
Gender (male, female) 2.1 (0.7-5.9) .151 Comorbidity (no, yes) 0.9 (0.1-4.6) .947 Smoking (no, yes) 0.6 (0.1-2.9) .544 Oral hygiene (good, poor) 1.2 (0.2-6.5) .768 Dental status Complete Reference
Partially 1.5 (0.5-4.1) .382 Edentulous 0.5 (0.6-4.9) .622 Velocity of fracture a (high, low) 1.6 (0.5-4.4) .364
Condyle fracture (with, without) 0.5 (0.1-1.6) .305 Fracture Single Reference
Single condyle 0.4 (0.1-1.5) .412 Bilateral 0.6 (0.2-1.9) .440 Bilateral condyle 0.7 (0.0-6.8) .760 Reduction techniques Forceps aided Reference
Non-forceps aided 4.5 (1.6-12.6) .004
Unit of analysis number of fracturesb
Location (Para)symphyseal Reference
Body 2.3 (0.6-8.4) .194 Angle 4.2 (1.2-14.5) .021 Fracture type Simple Reference
Comminuted 0.9 (0.2-3.3) .900 Incomplete 0.0 .999 Fixation Load sharing Reference
Load bearing 0.0 .999 Both 0.4 (0.6-3.9) .505 Reduction techniques Forceps aided Reference
Non-forceps aided 2.7 (1.0-7.4) .045
a Low velocity (fall, assault, sport and home accident), High velocity (motor vehicle and bicycle accident) b Fracture of the condyle and ramus (concomitant) were excluded (treated closed)
are shown in Table 3. The overall complications rate was higher in the non-forceps aided group compared to the non-forceps-aided group (P=.045 ;OR=2.7, 95% CI, 1.0-7.4).
Confounders
The possible confounding factors for complications are summarized in Table 4. Medical comorbidities were more frequently observed in the fractures reduced by the non-forceps aided group. However, there was no association between comorbidities and postoperative complications in logistic regression analysis. The fractures of the angle region had a higher complication rate compare to the (para)symphyseal region of the mandible.
3
DISCUSSION
Internal fixation of fractures is always preceded by reduction of the fractured fragments. In case of mandibular fractures this reduction can be achieved by either IMF, manual reduction and/or using a repositioning forceps 3–5. In daily
practice reduction starts at the moment IMF is applied or when dislocation is neutralized by hand. Additionally, in more complex or less stable cases, reduction can be facilitated and improved by using reduction forceps.
In this study, we analyzed the fracture alignment and postoperative complications of mandibular fractures reduced with or without the aid of repositioning forceps. The results of this study show that the additional use of a repositioning forceps in the treatment of mandibular fractures, even when they are more complex, result in a better alignment of the fragments and less complications compared to manual repositioning and/or IMF only. These results are in accordance with those of previous studies 2,10 indicating
that using repositioning forceps for the mandibular fracture decreases the postoperative complication rate and provides adequate reduction.
In this study, forceps aided reduction was mostly applied in the (para) symphyseal and body region, and less in the angle. The available forceps are less easy to apply in the posterior region. As this study has shown that a forceps is of additional value in mandibular fracture treatment, there is a need for development of a reduction forceps designed for application in posterior mandibular fractures.
One might expect that repositioning forceps would be used mainly to reduce simple, non-comminuted fractures. In our study, nearly half of the comminuted fractures were also reduced with the aid of repositioning forceps. In these cases, prior to fixation, the larger parts of comminuted fractures were first reduced with repositioning forceps, and then the smaller parts were fitted in. Independently of the reduction technique, complications were more often observed in the angle region compared to (para)symphyseal region of the mandible. This generally known from literature. Only a small number of fractures in the posterior region was treated with additional use of a forceps (Table 3). Therefore, we are not able to make a clear statement on the additional value of the use of forceps in this specific region.
It has to be mentioned that, in this retrospective study, the method of fracture reduction was selected by the surgeons, which could lead to incorporation of bias. However, the group of mandibular fractures studied was a representative sample of the mandibular fractures treated during the inclusion period. As these fractures are treated by several surgeons in out of office hours the surgeons could not select the patients or fractures. Therefore, results of this study can be generalized to other surgeons as well. The results show that, irrespective of the use of forceps in simple or comminuted fractures, the application of a reduction forceps favors a positive outcome of mandibular fracture treatment. Mandibular fractures reduced by the aid of repositioning forceps are accompanied by lower complication rates and better alignment.
ACKNOWLEDGMENTS
Authors would like to thank Otgongerel Nyamsambuu, for the drawing the figure.
