University of Groningen
Optimization of mandibular fracture treatment
Batbayar, Enkh-Orchlon
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Publication date: 2019
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Batbayar, E-O. (2019). Optimization of mandibular fracture treatment. University of Groningen.
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Chapter 9
Mandibular fractures are the most common injuries of the craniofacial region, and postoperative complications after surgical treatment occur in 20-26% of patients. The cause of these postoperative complications is related to poor fracture reduction, improper fixation, the severity of the trauma, fracture location and type, and general health conditions. Historically, numerous innovations have contributed to the improvement of mandibular fracture treatment. Although the outcome of mandibular fracture management is looked upon as satisfactorily, there still is room for improvement (Chapter 1). Therefore, the general aim of this thesis was to assess ways to improve mandibular fracture reduction and fixation by reviewing available fracture reduction methods, analyzing the effect of reduction forceps on postoperative complications, developing sophisticated reduction forceps, to analyze the added value of locking plate systems versus non-locking plate systems, compiling a treatment protocol for fractures of the edentulous mandible, and analyzing the difference between characteristics of condylar process fractures based on 2D respectively 3D imaging.
The study described in Chapter 2 reviews mandibular fracture reduction methods other than intermaxillary fixation. There are three basic approaches currently being used to reduce fractures of the mandible. First, reduction forceps. Quick and adequate reduction of fractures seems possible with reduction forceps resulting in anatomic repositioning and shorter operation time. Several modifications and new designs of the forceps have been proposed in the literature, but there is no reduction forceps available so far that really functions in the posterior region through an intraoral approach. Second, elastic rubber bands or metal wire loops fixed on screws placed across both sides of the fractured parts. Third, a vacuum-formed splint or 3D printed splint after computer-guided mandibular fracture reduction. These two methods are rather time-consuming. They have been used mainly in severely displaced fractures. Overall, the aforementioned fracture reduction methods are favorable in the dentate part of the mandible. A satisfying intraorally applicable solution for the posterior part of the mandible is not yet available.
The study described in Chapter 3 analyzed the added value of using reduction forceps in the treatment of mandibular fractures. For this study, a total of 131 consecutive patients with 252 mandibular fractures were included. In 54 patients the mandibular fractures were reduced without the aid of reduction forceps while in 77 patients the fractures were reduced with the aid of a reduction forceps. Fractures reduced with the aid of the forceps had a better postoperative fracture alignment. The overall complication rate was higher
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in the group of fractures reduced without the aid of forceps (17%) than in the forceps-aided group (7%). Taken together, these findings highlight the potential usefulness of reduction forceps in the reduction and fixation of mandibular fractures. Moreover, the findings clearly indicate that there is a need for reduction forceps that are suitable for use in the posterior part of the mandible.
The study described in Chapter 4 was undertaken to design, develop and evaluate new fracture reduction forceps for use in the treatment of mandibular fractures. We designed and developed three fracture reduction forceps, one for the (para)symphyseal area and a right and left one for the posterior region. The forceps were developed based on extensive morphological analysis and with respect to the drawbacks of currently available reduction forceps. Each forceps has a unique design which makes it applicable in the predetermined region of the mandible. This set of three reduction forceps is applicable for the reduction of almost any fracture of the anterior as well as the posterior region of the mandible. However, in cases of very oblique, flat fractures without sufficient interfragmentary stability reduction with any kind of forceps may be impossible due to sliding of the fractured parts.
The study described in Chapter 5 systematically reviewed the postoperative complications (including infection, hardware failure, and need for intermaxillary fixation) of mandibular fractures fixated with locking and non-locking plate systems, and critically assessed the methodological quality of the currently available systematic reviews. The quality of the included studies was evaluated with relevant assessment tools with regard to their study types and results were summarized. In total 33 studies, and 3 existing systematic reviews were revealed. The included studies had a large variety of comparison of different locking and non-locking plates, and the overall quality was poor. The comparison of these two plate systems was possible only 16 studies. The results of those studies suggested that locking plates are superior only concerning the need for intermaxillary fixation in the early and intermediate postoperative period although this may very well be explained by the surgeon habits and not because it was indispensable. In addition, the methodological qualities of the existing systematic reviews on the topic were low, which indicated that the current review was meaningful.
The study described in Chapter 6 compiled the obtainable knowledge about the treatment of fractures of the edentulous mandible. On the bases of the
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Chapter 9
current literate and our own experience, we compiled a treatment protocol for fractures of the edentulous mandible and hypothesized that this protocol would result in fewer complications. In total 42 consecutive edentulous patients with mandibular fractures were identified of whom 36 patients with 61 fractures met the inclusion criteria. The mean age of the patients was 66±13 years, and 19 were men (52.8%). Of 61 fractures, 19 were severely atrophic mandibles (≤10 mm), 24 were atrophic mandibles (>10 mm), 16 were fractures of the condyle, and 2 were ramus fractures. Among these fractures, the treatment protocol was followed in a total of 53 fractures, and the complication rate in this group was 7.5 % (4 of 53). The treatment protocol was not followed in 8 fractures, and the complication rate was 50% (4 of 8). The reoperation rate was 2% (1 of 53) in the first group and 50% (4 of 8) in the second group. These results suggest that following the compiled treatment protocol for fractures of edentulous mandibles significantly reduces postoperative complications and as well as reoperations.
The study described in Chapter 7 analyzed unilateral fractures of the condylar process in 32 patients using 3D measurements (3D displacement and rotations). The results were correlated with commonly used condylar fracture classifications of Loukota and Spiessl & Schroll. It was found that according to the Loukota classification, condylar neck and diacapitular fractures had the largest median 3D displacement as well as highest rotation of fracture fragments. With regard to Spiessl & Schroll classification, high condylar fractures with dislocation (type V) and diacapitular fracture (type VI) had the largest median of 3D displacement and also higher rotation in comparison to other types. It is possible that these higher 3D displacement and rotations are the result of attachment of the lateral pterygoid muscle to the condylar neck and head. Although the 3D measurements are precise, objective and reproducible, it is not known at this point whether the large 3D displacement and rotation of the condylar neck and diacapitular fractures have a clinical relevance or not. Moreover, we found a low negative correlation between MMO and 3D displacement and moderate correlation with rotation on the Z-axis. In other words, regardless of fracture classifications, the higher the 3D displacement or rotation on the Z-axis, the smaller the mouth opening was.
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CONCLUSION
The research described in this thesis has shown that optimization of treatment of mandibular fractures is possible although the outcome of mandibular fracture management is generally looked upon as satisfactorily.
This study provides the first comprehensive assessment of fracture reduction forceps. The results show that there is an added value of using forceps in the treatment of mandibular fractures. The fracture alignment is better, the complication rate is lower and the operation time is shorter. Three reduction forceps have been developed for the mandible that allow to reduce almost any mandibular fracture through an intraoral approach.
Despite the lack of appropriate studies included in the systematic review, the locking plate systems only have a significant impact on the postoperative need for intermaxillary fixation although this may well be caused by the preference of the surgeons and not by the choice of IMF.
With respect to treatment of fractures of the edentulous mandible, the proposed treatment protocol is not strongly evidence based, but based on the best available data in the literature plus clinical experiences within the UMCG. Strictly following the protocol described can be considered as best practice. The rate of complications and reoperations will decrease. Consequent use of the protocol and evaluation of results will extend the knowledge regarding this topic.
An important aspect of optimizing the treatment of condylar process fractures may be exact diagnosis and classification. Quantitative 3D measurements provide precise, objective, and reproducible information about condylar fractures. It allows the surgeon to classify the fractures exactly when, for instance, using the classification of Loukota or Spiessl & Schroll. The 3D measurements may well influence the choice for one or another treatment modality. However, further studies that focus on clinical parameters and the comparison of treatment modalities are needed to determine the true indication for open respectively closed treatment.
