study the use of simple and effective methods for the treatment of mandibular fractures.

[Drsumitra]

There is always a search for a treatment which gives faster and perfect results without any side effects.  Unfortunately such treatment does not exist especially for traumatic mandibular fractures.

The basic principle of any fracture treatment is reduction, fixation, immobilization, prevention of infection and rehabilitation. IMF provides both fixation and immobilization in cases of favorable fractures but prolong immobilization is required.  On the other hand, plating provides only fixation and immobilization is done by IMF, but it is required for a lesser period of time.  Various authors like Terris DJ, et al,¹ (1994) and Sorel B2 (1998) have reviewed the indications for closed and open reduction.  Closed reduction was the most frequently used method with minimal complication rate.

In favorable fractures, the results in terms of occlusion, mouth opening and cosmesis are equal and comparable by both of the methods.  The technique employed in the individual case will reflect the preference of the surgeon and the availability of specialized surgical facilities. If the treatment provider is comfortable in both the techniques, choice can be given to patients.
Closed reduction and intermaxillary fixation was the only method for centuries.  Most mandibular fractures were treated either by approximate fixation using internal stainless steel wires, external fixation using rigid metal pins or custom-made silver cap splints (cast metal covering of all the teeth in the arch).  The major disadvantage of this method is that the patient has to survive on a liquid diet for 4 to 6 weeks and oral cleaning cannot be properly done due to wiring and closed mouth.

One important factor worth noting is weight loss due to dietary restrictions.  In our study, patients lost an average of 3.9kg weight.  Maximum weight loss was 11kg.  This is especially of concern when the patients are already underweight or malnourished or has other associated debilitating injury.  It has to be mentioned here that open reduction and plating are best for those people who are professional voice users and require full mouth opening as soon as possible.  Our set of patients did not have any patients in this category.

If a patient wearing IMF requires airway assistance due to some other cause, it becomes difficult and time consuming.  There have been occasional incidences of prick injuries to the operator while performing IMF.  If the patient is suffering from sero communicable disease, repeated manipulation of wires is potentially hazardous.

Internal fixation with plates, pins or screws eliminates the need for prolonged intermaxillary fixation but has its own disadvantages of anesthetic/surgical risks apart from the cost of fixtures.  Initial results of internal fixation with plating were encouraging and enthusiastic.

Omar Abubaker, Gregg. T.Lyman³ in 1988 found from their 3 year study that even though the actual cost of ORIF throughout the study period was higher than that of closed reduction, when the cost of treating postoperative complications, the use of the ICU and the number of postoperative follow up visits was considered the use of ORIF was found to be more cost effective than closed reduction and MMF.  In a similar study, Brian.L.Schmidt, Gerard Kearns, Newton Gordon, Leonard Kaban⁴ in the year 2000 comparing the cost effectiveness of mandibular fracture treatment found that even though the initial cost of ORIF is more than double that of closed reduction, the overall cost of treating patients by ORIF was much lesser than that for closed reduction.

Later clinicians started critical comparison between open and closed reduction of mandibular fractures.
A more recent randomized study on financial analysis of closed versus open reduction method described by Schmidt BL. ,et al,⁴ (2000) and Shetty V ,et al, ⁵ (2008) with respect to cost of primary and secondary surgery and visits to the clinic for immediate and delayed complications showed that closed reduction of mandibular fracture cost significantly less than open reduction.

For both of the methods, the average hospital stay and follow up visits remains almost the same.  Thus cost of transport for the treatment and loss of working days would be equal.  The difference is in the fixtures and procedure cost of the treatment. In a government hospital like ours, surgical charges are minimal. All the instruments and fixtures are available in government supply.  Even then when given a choice for deciding their treatment, patients usually decided for closed reduction and IMF. Hence, it is expected that when they have to pay extra for surgery, anesthesia and fixtures, they would be even less willing to select an open reduction.  It is sometimes based on their mindset which is influenced by socio-familial belief. They consider closed reduction and IMF a non-surgical treatment as there is no incision and stitches. Patients were even prepared for restricted and liquid diet as part of therapy. Many patients observe self restriction to various foods for early and uncomplicated recovery from most illness. Dietary restriction and mouth closure for a few weeks was not considered to be a limitation by the patient.

Conclusion

Closed reduction and IMF is a commonly accepted method for treatment of traumatic mandibular fracture when the patient is not a professional voice user.  Closed reduction and IMF gives good results in the form of mouth opening, occlusion and cosmesis for a majority of patients having mandibular fracture.  Some weight loss is bound to occur but it is of concern if the patient is already malnourished or underweight.

 

  

 

        

[Drsumitra]

With increasing mandibular atrophy, the physical size of the mandible decreases. In the severely atrophic mandible, even very minor trauma can cause fracture. Additionally, pathologic fracture during mastication can occur. Very often, due to the fragile nature of the jaw, these fractures occur bilaterally.
Orthopantomogram (OPG), mandible series radiograph and CT scans can be used to diagnose and plan the treatment of the atrophic edentulous mandible fractures.

 

 

Axial CT scan showing bilateral fractures.
Note that although there appears to be a large bone stock, this patient’s mandible has only approximately 7 mm of vertical height.

Observation and soft diet

Observation may be indicated for patients medically unfit for general anesthesia. Atrophic edentulous mandible fracture patients are often elderly with medical problems presenting severe anesthetic risks.
One major complication of observation and soft diet would be nonunion of the mandibular fracture.

Closed reduction

Historically, atrophic edentulous fractures were treated closed by wiring in the patients dentures or fabricating Gunning style splints with postoperative mandibulomaxillary fixation (MMF).
Standard treatment with closed reduction often resulted in prolonged periods of MMF which was difficult for these patients. Additionally, the fractures were often poorly aligned. Postoperative malunions and nonunions were very common
ORIF

Indications for ORIF are any displaced atrophic mandible fracture requiring surgical intervention.
Following the AO principles of anatomic reduction of fractures and immediate function, ORIF of atrophic edentulous mandible fractures with load-bearing osteosynthesis has a distinct advantage for these patients. The technique has evolved to provide the patient with an excellent chance for mandibular union while the ability to masticate is preserved.
Literature has supported the efficacy of this technique.

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External fixation

Indications of external fixator might be the temporary stabilization of a fracture while the patient is treated medically, or if soft-tissue maturation around the fracture site is required.

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Complications,including malunion and nonunion are significant when external fixators are used as they do not provide absolute stability at the fracture site.
3 Treatment of an edentulous atrophic fracture with a reconstruction plate

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In the following, the treatment of an edentulous atrophic fracture with a reconstruction plate is described step-by-step.
4 Approach

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Extraoral appraoch

When treating atrophic edentulous mandible fractures, the surgeon will generally find it easier to use an extraoral surgical approach. The fracture fragments can be manipulated under direct visualization and stabilized while the reconstruction plate is being bent and applied to the mandible.

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Intraoral approach

An intraoral approach is possible but technically more difficult as the surgeon will need several sets of trained hands just to retract the soft tissues of the cheeks and tongue. Additionally, stabilization and fixation of the fractures is much more difficult via an intraoral approach. One should also be aware that the inferior alveolar nerve is located on the superior surface of the atrophic mandible. Therefore one must be extremely careful making intraoral incisions to expose atrophic fractures, or the nerve can be damaged.

 

        

[Drsumitra]

Disruption of the endosteal and periosteal blood supply occurs with the initial trauma, and maintaining adequate blood supply to the fracture site is essential for healing. Hunter described the 4 classic stages of natural bone repair: inflammation, soft callus, hard callus, and remodeling. The inflammation stage begins soon after injury and appears clinically as swelling, pain, erythema, and heat. Disrupted local vascular supply at the injured site creates a hematoma and prompts the migration of inflammatory cells, which stimulate angiogenesis and cell proliferation. After the initial inflammatory phase, the soft callus stage begins with an infiltration of fibrous tissue and chondroblasts surrounding the fracture site. The replacement of hematoma by this structural network adds stability to the fracture site.

Soft callus is then converted into rigid bone, the hard callus stage, by enchondral ossification and intramembranous bone formation. Once the fracture has united, the process of remodeling begins. Fibrous bone is eventually replaced by lamellar bone. Although this process has been called secondary bone union or indirect fracture repair, it is the natural and expected way fractures heal. Fractures with less than an anatomic reduction and less rigid fixation (ie, those with large gaps and low strain via external fixator, casting, and intramedullary [IM] nailing) heal with callous formation or secondary healing with progression through several different tissue types and eventual remodeling.

Anatomic reduction and absolute stabilization of a fracture by internal fixation alter the biology of fracture healing by diminishing strain (elongation force) on the healing tissue at the fracture site. Absolute stability with no fracture gap (eg, via ORIF using interfragmental compression and plating) presents a low strain and results in primary healing (cutting cone) without the production of callus. In this model, cutter heads of the osteons reach the fracture and cross it where bone-to-bone contact exists. This produces union by interdigitation of these newly formed osteons bridging the gap. The small gaps between fragments fill with membranous bone, which remodels into cortical bone as long as the strain applied to these tissues does not cause excessive disruption and fibrous tissue develops (nonunion). This method of bone healing is known as direct bone healing or primary bone union. Essentially, the process of bone remodeling allows bone to respond to the stresses to which it is exposed.

Based on the mechanical milieu of the fracture as dictated by the surgeon’s choice of internal fixation and the fracture pattern, 2 patterns of stability can result that determine the type of bone healing that will occur. Absolute stability (ie, no motion between fracture fragments) results in direct or primary bone healing (remodeling). Relative stability (ie, a certain amount of fragment motion) heals with secondary or indirect bone union.

 

        

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