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OBJECTIVE: To describe an alternative technique for mandibular stabilization during repair

STUDY DESIGN: Clinical case series

METHODS: This is a retrospective review of three consecutive subjects with mandibular malunion or nonunion who underwent revision open reduction internal fixation (ORIF) with temporary stabilization by placing a temporary 2.4mm locking reconstruction plate at the inferior border of the mandible.

RESULTS: Three patients with a mean age of 41.0 ( 12.0) years underwent a total of four operations for malunion or nonunion of the mandible. All three patients were known IV drug users. Average time from initial surgery to revision was 65.0 19.4 days. For two of the operations, placement of a temporary stabilization reconstruction plate was indicated due to the need for improved stabilization as an alternative to intraoperative maxillo-mandibular fixation (MMF). For the other two operations, a temporary stabilization plate was used in conjunction with intraoperative MMF to allow for improved stabilization of complex mandibular fractures; iliac crest bone grafting was performed during both of these revisions.

CONCLUSIONS: •Temporary stabilization with a reconstruction plate at the inferior border of the mandible is a viable technique for mandibular stabilization as an alternative to MMF and intraoral cortical bone screw fixation (ICBSF)•The temporary stabilization plate eliminates the need for arch bar placement with associated risk of wire puncture•In selected cases, the inferior border reconstruction plate offers the ability to maintain mandibular stability while placing the fixation plate. This technique is superior to ICBSF and MMF, especially during revision ORIF with poor or loose dentition, severely comminuted fractures or fractures with bony defects.

Temporary Stabilization during Mandibular Fracture Repair Using an Inferior Border Reconstruction Plate

Megan L. Durr, MD; Ruwan Kiringoda, MD; Andrew N. Goldberg, MDDepartment of Otolaryngology – Head & Neck Surgery

University of California - San Francisco

Three patients with a mean age of 41.0 ( 12.0) years underwent a total of four surgeries for nonunion of the mandible. All three patients were known IV drug users. Average time from initial surgery to revision was 65.0 19.4 days. For two of the surgeries, placement of a temporary reconstruction plate on the inferior border was indicated to stabilize the mandibular segments during ORIF as an alternative to intraoperative maxillo-mandibular fixation. For the other two surgeries, a temporary reconstruction plate was used in conjunction with intraoperative MMF to allow for improved stabilization of complex mandibular fractures; iliac crest bone grafting was performed during both of these revisions.

The successful treatment of mandibular fractures depends on fracture reduction, stabilization of the fractured segments of the jaw, and restoring premorbid dental occlusion.8 Normal healing is “bony union” in which the fractured bone end is united by new bone tissue, with anatomic reduction and fixation resulting in restoration of function and prevention of deformities. 9

A study by Li et al showed that those more likely to develop abnormal unions were males, age 31-40,and the most common etiology of the mandible fracture was road traffic accidents. A study by Lamphier et al of 594 mandible fractures at an urban teaching center reported a 4.8% rate of nonunion with most occurring in the mandibular angle.3 This study also found that a statistically significant higher number of nonunions occurred after mandibular plate fixation compared with the closed reduction group.3 Biller et al showed that the risk of infectious complications after mandible fracture is significantly increased with regular substance abuse.10

A study by Mathog described a 2.8% rate of nonunion with 56% of subjects having multiple fractures compared to only 27% of subjects having uncomplicated single unilateral fractures.2 In this series, continued infection was treated by culture, drainage, debridement, and stabilization of the mandible with either internal or external rigid fixation.

ORIF is now the treatment of choice for complicated mandible fractures. Maintaining stable occlusion for fracture reduction and placement of the reconstruction plate can be difficult during ORIF of complicated mandible fractures even with the use of ICBSF or intra-operative MMF .8 Placement of arch bars for MMF can increase the risk of human immunodeficiency virus (HIV) and hepatitis B virus (HBV) transmission to the surgeon and is the single greatest cause for accidental puncture surgeons who perform this procedure.11-15

Poor or loose dentition, severe comminution, and a significant bony defect between segments contribute to persistent instability despite MMF or ICBSF. In selected cases of persistent mandibular segment instability, stabilization with a temporary reconstruction plate placed on the inferior border offers a superior alternative to MMF or ICBSF.

This is a retrospective study which includes consecutive subjects with mandibular malunion or nonunion who underwent repair with temporary stabilization with a temporary 2.4mm locking reconstruction plate at the inferior border of the mandible from September 2010 to June 2011..

Temporary stabilization with a reconstruction plate at the inferior border of the mandible is a viable technique for mandibular stabilization as an alternative to MMF and ICBSF. The temporary stabilization plate eliminates the need for arch bar placement with associated risk of wire puncture. In selected cases, the inferior border reconstruction plate offers the ability to maintain stability while placing the fixation plate which is superior to ICBSF and MMF, especially during revision ORIF with poor or loose dentition, severely comminuted fractures or fractures with bony defects.

The overall complication rate for all mandibular fractures is reported to be 9-36% in multiple studies.1Common complications described are facial deformity, disturbance of facial sensation, temporomandibular joint pain, malocclusion, wound infection, osteosynthesis failure, malunion, nonunion, and pseudoarthrosis.1 Of these, nonunion is often the most challenging to treat.

A number of contributory factors for the development of mandibular malunion or nonunion have been proposed, including repeat trauma after fixation, failure to provide antibiotics, presence of teeth in the fracture line, alcohol and drug abuse, inexperience of the surgeon, lack of patient compliance, comminuted fractures, and anatomic location.2-7 Inadequate union may also directly result from poor mechanical environment due to a large gap between the fractured ends or mobilization of fractured ends, and poor biological environment at the fracture site.5

For primary open reduction internal fixation (ORIF) of mandible fractures, arch bars can be used for placing the patient in temporary maxillomandibular fixation (MMF) to ensure proper dental occlusion before fracture reduction.8 Intraoral cortical bone screw fixation (ICBSF) may also be employed as a temporary method of obtaining occlusion.8 The application of arch bars with the requisite passage of circumdental wires, increases the chance of skin punctures and blood-borne disease transmission and increases operative time.8

Maintaining occlusion and stability can be difficult during repair of complicated mandible fractures due to poor or missing dentition, missing bone, or severe comminution. During revision mandible ORIF, which is commonly required for patients with malunion and/or nonunion, the original reconstruction plate must be removed and replaced with a new internal or external fixation device. This study describes a technique for intraoperative stabilization using a temporary reconstruction plate placed at the inferior border of the mandible. This plate serves to hold the mandible in proper occlusion while the original reconstruction plate is removed and the new fixation device is replaced. This avoids the need for temporary arch bars or ICBSF eliminating the previously described risks of arch bar placement and blood-borne disease transmission and may decrease operative time.

INTRODUCTION

METHODS AND MATERIALS

1. van den Bergh B, Heymans MW, Duvekot F, Forouzanfar T. Treatment and complications of mandibular fractures: A 10-year analysis. J Craniomaxillofac Surg 2011.

2. Mathog RH, Toma V, Clayman L, Wolf S. Nonunion of the mandible: an analysis of contributing factors. J Oral Maxillofac Surg 2000;58:746-52; discussion 52-3.

3. Lamphier J, Ziccardi V, Ruvo A, Janel M. Complications of mandibular fractures in an urban teaching center. J Oral Maxillofac Surg 2003;61:745-9; discussion 9-50.

4. Ellis E, 3rd. Complications of rigid internal fixation for mandibular fractures. J Craniomaxillofac Trauma 1996;2:32-9.5. Caylakli F, Yavuz H, Cagici AC, Ozluoglu LN. Endoscopic sinus surgery for maxillary sinus mucoceles. Head Face Med 2006;2:29.6. Passeri LA, Ellis E, 3rd, Sinn DP. Relationship of substance abuse to complications with mandibular fractures. J Oral Maxillofac Surg

1993;51:22-5.7. Adell R, Eriksson B, Nylen O, Ridell A. Delayed healing of fractures of the mandibular body. Int J Oral Maxillofac Surg 1987;16:15-24.8. Vartanian AJ, Alvi A. Bone-screw mandible fixation: an intraoperative alternative to arch bars. Otolaryngol Head Neck Surg

2000;123:718-21.9. McKibbin B. The biology of fracture healing in long bones. J Bone Joint Surg Br 1978;60-B:150-62.10. Biller JA, Pletcher SD, Goldberg AN, Murr AH. Complications and the time to repair of mandible fractures. Laryngoscope

2005;115:769-72..11. Busch RF, Prunes F. Intermaxillary fixation with intraoral cortical bone screws. Laryngoscope 1991;101:1336-8.12. Busch RF. Maxillomandibular fixation with intraoral cortical bone screws: a 2-year experience. Laryngoscope 1994;104:1048-50.13. Davidson TM, Stabile B. Acquired immunodeficiency syndrome precautions for otolaryngology-head and neck surgery. Arch

Otolaryngol Head Neck Surg 1991;117:1343-4.14. Benninger MS, Gupta N, Gilmore K. Intraoperative infectious disease exposure to otolaryngology operating room personnel.

Laryngoscope 1991;101:1276-9.15. Martinez-Gimeno C, Acero-Sanz J, Martin-Sastre R, Navarro-Vila C. Maxillofacial trauma: influence of HIV infection. J Craniomaxillofac

Surg 1992;20:297-302.

CONCLUSIONS

DISCUSSIONRESULTS

REFERENCES

Table 1. Clinical characteristics of subjects

Figure 1. Original plate in setting of mandibular non-union

Figure 2. Placement of temporary stabilization plate prior to removal of

original hardware

ABSTRACT

Figure 4. Placement of revision plate in setting of temporary stabilization

bar

Figure 3. Removal of native hardware, with temporary stabilization

plate in place

1 53 M Yes HIV, Hepatitis C2 41 M Yes None3 29 M Yes Hepatitis C

Patient Number

Age at presentation (years)

Sex Known IVDU

Blood borne illnesses

Patient Number

Initial injury Cause of injury

Initial hardware placed Indication for revision Cause of complicationDays after

initial surgery

Reason for placement of temporary stabilzation

bar

New hardware placed

1

Right parasymphyseal and left subcondylar fracture.

Blunt trauma assault

2.4mm reconstruction plate placed at right parasymphyseal fracture, MMF for left subcondylar fracture.

Nonunion of right parasymphyseal fracture

Additional trauma after ORIF, noncomplicance with antibiotics, dental abscess, osteomyelitis

56Inadequate dentition for MMF; need for improved stabilization

2.4mm reconstruction plate

2Left parasymphyseal and right body mandible fracture

Blunt trauma assault

Two 2.0mm miniplates placed at the left parasymphyseal fracture inferior and superior to the mental nerve. 2.4mm reconstruction plate placed at right body fracture.

Malunion of left parasymphyseal fracture

Additional trauma from assault after ORIF, noncompliance with soft diet and antibiotics

44

Need for improved stabilization despite MMF placement due to 2cm of missing bone

2.4mm reconstruction plate

2 (second

operation)

Nonunion of left parasymphyseal fracture

Noncompliance with soft diet and antibiotics, osteomyelitis

71Inadequate dentition for MMF; need for improved stabilization

2.4mm reconstruction plate and cancellous bone graft

3Left parasymphyseal and right body mandible fracture

Blunt trauma assault

2.4mm reconstruction plate placed at left parasymphyseal and right body fracture.

Nonunion of right body fracture

Noncompliance with soft diet, antibiotics, methamphetamine usage, osteomyelitis

89

Need for improved stabilization despite MMF placement due to 1cm of missing bone

2.4mm reconstruction plate and cancellous bone graft

Table 2. Clinical and operative data for subjects

Figure 5. Completion of procedure, illustrating removal of temporary stabilization bar following

revised hardware