135

Treatment of extensive comminuted mandibular fracture between both mandibular angles with bilateral condylar fractures

using a reconstruction plate: a case report

Kwonwoo Lee1, Kyuho Yoon1, Kwan-Soo Park1, Jeongkwon Cheong1,

Jaemyung Shin2, Jungho Bae1, Inchan Ko1, Hyungkoo Park1

Department of Oral and Maxillofacial Surgery, 1Sanggye Paik Hospital, Seoul, 2Ilsan Paik Hospital, Goyang, Inje University College of Medicine, Korea

Abstract (J Korean Assoc Oral Maxillofac Surg 2014;40:135-139)

This following case report describes the open reduction, internal fixation and the reconstruction of an extensive comminuted mandibular fracture with bilateral condylar fractures in a 19-year-old male patient with an intellectual disability and autistic disorder. He suffered fall trauma, resulting in shat-tered bony fragments of the alveolus and mandibular body between both mandibular rami, the fracture of both condyles and the avulsion or dislocation of every posterior tooth of the mandible. The patient underwent open reduction and internal fixation between both mandibular rami using a reconstruc-tion plate, open reduction and internal fixation of the shattered fragments using miniplates and screws, and the closed reduction of the bilateral condylar fractures.

Key words: Fractures, Comminuted, Mandibular fractures, Fracture fixation[paper submitted 2014. 3. 27 / revised 2014. 5. 9 / accepted 2014. 5. 22]

Traditionally,extensivecomminutedmandibularfractures

havebeenconsideredtobeindicationsforclosedreduction

inordertoavoidperiostealstrippinganddevascularization

of thecomminutedbonesegments5. In the last30years,

however,therehasbeenachangeinthetreatmentperspec-

tiveofsuchinjuriesdrivenbyadvancementsinrigidfixation

techniques2.Somereports3,5-7 insistthatopenreductionand

internalfixationisabettertreatmentoptionandcauseslower

complicationrates thanclosedreductioninsomecommi-

nutedmandibularfractures.However,itisstillcontroversial

whetherclosedreductionistheoptimaltreatmentforcom-

minutedfracturesascomparedtoopenreductionandinternal

fixation.

Thedecisionforthepropertreatmentcanbecomplicated

whencondylarfracturesaccompanythecomminutedman-

dibularfracture.Closedreductionswithlong-termlimitation

ofmouthopeningarebeneficialforcomminutedfracture,but

areharmfulforcondylarfractures.

Therearetwotypesofcondylarfractures,intracapsularand

extracapsular,butforpracticalpurposes,theanatomicallevel

ofthefractureisdividedintothreesites:thecondylarhead

(intracapsular), thecondylarneck(extracapsular),andthe

I. Introduction

Comminutedfractureisdefinedasthepresenceofmultiple

fracturelinesresultinginmanysmallpieceswithinthesame

areaofthemandible(e.g.,angle,body,ramus,orsymphysis)1.

Inextensivecommunitedfractures,multiplesites(exceed-

ingoneregionandinvolvingtheneighbouringregion)ofthe

mandiblearesplintered,crushed,pulverized,orbrokeninto

severalpieces1,2.Extensivecomminutedmandibularfractures

occurwhenahigh-energyimpactisappliedontoaregionof

themandible.Thehigh-energyimpactseeningunshots,traf-

ficaccidents,andfallscanleadtoenoughconcentratedforce

onthemandibletocausemultiplesitesofcomminutedfrac-

tures3,4.

CASE REPORT

Kwan-Soo ParkDepartment of Oral and Maxillofacial Surgery, Inje University Sanggye Paik Hospital, 1342, Dongil-ro, Nowon-gu, Seoul 139-707, KoreaTEL: +82-2-950-1161 FAX: +82-2-950-1167E-mail: OMS_kspark@paik.ac.kr

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Copyright Ⓒ 2014 The Korean Association of Oral and Maxillofacial Surgeons. All rights reserved.

http://dx.doi.org/10.5125/jkaoms.2014.40.3.135pISSN 2234-7550·eISSN 2234-5930

J Korean Assoc Oral Maxillofac Surg 2014;40:135-139

136

stabilizationofhisjawsforclosedreductionandhistibial

fracturekepthimonstrictbedrest.

Undergeneralanesthesia,openreductionandinternalfixa-

tionofthemandibularcomminutedfracturewereperformed

usingalockingreconstructionplate,mini-platesandscrews.A

lockingreconstructionplate(Stryker-Leibinger,Kalamazoo,

MI,USA)wasadjustedandfixedtobothramiwithscrews.

Marginalbonesegmentswerereducedandfixedtothere-

constructionplatewithscrews.Smallornon-marginalbone

segmentswerereducedandfixedtoeachotherandmarginal

bonewithmini-platesandscrews.Softtissuewereattachedto

theperiosteumandsuturedwithvicryl.Theclosedreduction

ofbothcondylarfractureswasfollowedbymaxillomandibular

fixationwithsteelwiresbetweenthearch-baronthemaxillary

teethandthereconstructionplateonthemandible.(Fig.2)

subcondylarregion8-10.Condylarfracturesareusuallycaused

bytrafficaccidents,falls,andviolence8.Teethinjuriessuch

asfracturesandluxationsarefrequentlyaccompaniedwith

condylarheadorneckfractures.Concomitantfracturesofthe

mandibularbodyoftenaccompanysubcondylarfracturesand

aremorefrequentlybilateralthanunilateral11.

In thetreatmentofcondylarfractures, thereareconser-

vativemethodssuchasclosedreductionwithconcomitant

physicaltherapy,andsurgicalmethodsusingopenreduction

andinternalfixation.Likeothermandibularfractures, the

treatmentofcondylarfracturesiscontroversial12.Forcon-

servativemethodsusingclosedreduction,earlymouthmo-

bilizationisessentialtopreventadhesionorankylosisofthe

temporomandibularjoint(TMJ).

Thisarticlereportsacaseofextensivecomminutedman-

dibularfracturewithbilateralcondylarfracturestreatedby

openreduction,internalfixation,andreconstruction,anddis-

cussestheindicationsandbenefitsoftreatmentoptions.

II. Case Report

A19-year-oldmalewhowasinthecareofaninstitution

forthedisabledduetoanintellectualdisabilityandautistic

disordervisitedtheemergencyroomatInjeUniversityIlsan

PaikHospital(Goyang,Korea)afterafall.Hisinjuryinclud-

edextensivecomminutedmandibularfracturebetweenboth

angles,bilateralcondylarfractures,theavulsionordisloca-

tionofallposteriorteethinthemandible,andshatteredbony

fragmentsofthealveolusandmandiblebody.Accordingly,

therewasadefectofmandiblecontinuityandocclusionwas

absent.(Fig.1)Hisfacialinjurieswereaccompaniedbyfrac-

turesontherighttibiaandankle.Tomakemattersworse,his

psychologicalstatemadeitimpossibleforhimtomaintain

Fig. 1. Preoperative images of com-puted tomography axial view and three-dimensional reconstruction view. There are scattered fragments of mandible andposterior teeth.Kwonwoo Lee et al: Treatment of extensive commi-nuted mandibular fracture between both mandibular angles with bilateral condylar fractures using a recon-struction plate: a case report. J Korean Assoc Oral Maxillofac Surg 2014

Fig. 2. Intraoperative photo showing a reconstruction plate, mini-plates and screws used for internal fixationand steel wires used for maxillomandibular fixation.Kwonwoo Lee et al: Treatment of extensive comminuted mandibular fracture between both mandibular angles with bilateral condylar fractures using a reconstruction plate: a case report. J Korean Assoc Oral Maxillofac Surg 2014

Treatment of extensive comminuted mandibular fracture using a reconstruction plate

137

dietofsoft-to-mildlyhardsolids,andmorethan30mmof

mouthopeningwasmeasured.Althoughitwasimpossible

toachievepanoramicradiographsandcomputedtomogra-

phyduetothepatient’spsychologicalproblems,infections

orbonenecrosiswerenotobserved,andsignsofnon-union

werenotfoundonplainradiographsandclinicalexamination

uptothistime.(Fig.5)

Reconstructionofthemandiblecontinuityandrehabilita-

tionoforalfunctionslikedietingandmouthopeningrecov-

eredwithoutsignificantcomplications.

Morefollow-uphospitalvisitswerenotpossibledueto

personalreasons,althoughhisconditionwasreportedover

thephonebyhisguardian.Anyspecificcomplicationsin-

volvingthemandibledidnotoccurformorethanoneyear.

III. Discussion

Comminutedmandibularfractureshavebeentreatedby

severalmethods:closedreduction,externalpinfixation,inter-

nalwirefixation,andopenreductionandinternalfixation.It

hasbeendebatedwhetherclosedreductionoropenreduction

andinternalfixationisthepropertreatmentforcomminuted

mandibularfractures.Forextensivecomminutedmandibular

fractures,closedreductionhaslongbeenconsideredtobethe

optimaltreatmenttopreservebloodsupplytothebonefrag-

mentsandtopreventsecondaryinfections.However,since

Kazanjian6describedtheopenreductionandinternalfixation

ofmandibularcomminutedfractures60yearsago,ithasbeen

Twoweeks later, themaxillomandibular fixationsteel

wireswerereleasedandthepatientstartedmouth-opening

exercisesforcondylerehabilitationtopreventTMJcomplica-

tions.Twentymillimetersofmouthopeningwasmeasured.

Thepatientwasallowedaliquiddietperoralandwheelchair

ambulationfourweeksaftertheoperation.Aftersixweeks,

23mmofmouthopeningwasmeasured(Fig.3)andfavor-

ablebonehealingandsofttissuematurationwereobserved.

(Fig.4)After10weeks, thepatientwasable tohavea

Fig. 3. At postoperative 6 week follow-up, 23 mm of mouth open-ing was measured.Kwonwoo Lee et al: Treatment of extensive comminuted mandibular fracture between both mandibular angles with bilateral condylar fractures using a reconstruction plate: a case report. J Korean Assoc Oral Maxillofac Surg 2014

Fig. 4. Extraroal photograph of the 6-weeks after the surgery show-ing favorable healing of soft tissue.Kwonwoo Lee et al: Treatment of extensive comminuted mandibular fracture between both mandibular angles with bilateral condylar fractures using a reconstruction plate: a case report. J Korean Assoc Oral Maxillofac Surg 2014

Fig. 5. Posterior-anterior view image of the 10-weeks after opera-tion. Signs of non-union were not found.Kwonwoo Lee et al: Treatment of extensive comminuted mandibular fracture between both mandibular angles with bilateral condylar fractures using a reconstruction plate: a case report. J Korean Assoc Oral Maxillofac Surg 2014

J Korean Assoc Oral Maxillofac Surg 2014;40:135-139

138

associatedwithfracture(s)elsewhereinthemandibleand/or

involvingcomminutedmaxillaryfractures.Ifopenreduction

andrigidinternalfixationistobeusedforothermandibular

ormaxillaryfractures,itmayalsobeusedforsubcondylar

fracturestoavoidintermaxillaryfixation.”5)“Openreduc-

tionisrecommendedwhenitisimpossibletoachievepre-

traumaticoradequateocclusionbyclosedreduction,incases

whereconservativetherapyhasfailed,andinanterioropen

biteresults”.

Titaniumplatesandscrewsaremostlyusedfor internal

fixation,andtheplatesystemswidelyusedare1.3,1.5,and

2.0mmminiplatesystemsforordinaryfracturesand2.4

and2.7mmreconstructionplatessystemsforcomminuted

fractures16.Amandibularreconstructionboneplatecanbe

usedtobridgethecomminutiongapandstabilizethemost

proximalanddistalsegments.Ifmajorfracturedfragments

areimmobilized,otherminorfragmentsbetweenthemajor

segmentscanhealwellevenifunfixed7.Therearetwode-

signsofplate-screwlockingsystems,withtheconvention

beingnon-lockingandtheotherbeinglocking.Non-locking

systemsachievestabilitybythecompressionbetweenthe

screwheadcompassed-plateandthescrew-boneinterface,

whichrequiresanatomicallyreducedfragmentsandprecisely

fittedplates.Thedrawbacksofthissystemarethepossibility

ofprimaryreduction-lossincaseswithincompletelyadapted

platesanddisturbancesofthebloodsupplytothecompressed

cortex.Inthelattersystem,thescrewheadislockedatboth

threadsoftheplateandbone,creatingnocompressionbe-

tweentheplateandbone.Thissystemcanproducemorerig-

idconstructionwithlessdistortionofthereducedfragments

andlesshindrancestobloodcirculation.Itsmeritsinclude:(1)

lessprecisionrequiredinplateadaptation,(2)lessalterations

inreducedbonesegmentsandtheocclusalrelationshipon

screwtightening,(3)greaterstabilityacrossthefracturesite,

(4)lessscrewloosening16,17.Forthereasonsabove,thelock-

ingreconstructionplatesystemcanbeavalidinternalfixation

toolforthetreatmentofcomminutedmandibularfractures.

Inthiscase,becausethefracturewassosevereandwide-

spread,discontinuityof themandibleoccurredsoitcould

betreatedbyeitherclosedreductionoropenreductionand

internalfixation.However,therewereseveralproblemsthat

madeclosedreductionlessfeasibleforthispatient.First,all

ofthepatient’sposteriorteethwereavulsedorexcessively

dislocated,thealveoluswasfractured,andstableocclusion

wascompletelyabsent.Second,bothcondylar fractures

causedretractionofthemandibleandearlymouthopening

exerciseswererequiredtoavoidadhesionofthecondyles,

reportedthatopenreductionandinternalfixationisabetter

treatmentwithlowercomplicationratesthanclosedreduc-

tionincomminutedmandibularfractures.Furthermore,there

havebeenremarkableadvancementsinfixationmaterialsand

techniques.Asaresult,openreductionandinternalfixation

tendstobethecontemporarytreatmentofchoice.

A recent reportbySmithandTeenier5 suggested that

openreductionandinternalfixationincasesofcomminuted

mandibularfracturesareindicated(a)insevereinjurieswith

significantdisplacementtoallowfortherestorationofthe

pre-traumaticanatomicrelationships,(b)intheedentulous

andpartiallyedentulouspatientwhodoesnothavestableoc-

clusionandmaybenefitfromtheopenreductionandinternal

fixationofcomminutedfractures,and(c)incaseswithmul-

tiplefracturesofthemidface,inwhichthemandibleserves

asaguidetorepositionthemidfacialbones.Theauthorsalso

proposedthatclosedreductionorconservativetreatmentisa

betterchoiceforminimallydisplacedcomminutedfractures.

Thehealingofdisplacedordislocatedcondylarfractures

requires theremodelingof thecondyles.Remodelingcan

beunderstoodasaprocessdirectedtomeetthedemandsof

functionandgrowth,andoccursinsuchawaytoallowfor

thefunctionaladaptationtocondylarrotationwithouttransla-

tion.Fordislocatedorseverelydisplacedcondylarheads,the

remodelingprocessconfigurestheheadparalleltothefrontal

plane13.

Forcondylarfractures,conservativetreatmentisthetreat-

mentofchoiceforthemajorityoffractures8.Ingeneral,early

mouthopeningexercises(i.e.,theearlymobilizationofthe

jawandfunctionalrehabilitation)isessentialforthetreatment

ofcondylarfractures14.Adhesion,fibrosis,andankylosisof

thecondylecanoccurafterlongperiodsofmaxillomandibu-

larfixation15.

Zachariadesetal.8proposedseveralguidelinesfortreating

condylarfractures, including:1)“Displacedcondylarfrac-

tureswithalteredocclusionmaybesatisfactorilytreatedin

50%ofcaseswithintermaxillaryfixation.Incaseswithdis-

placedfractures,maxilla-mandibularfixationshouldalways

beused,eveniftheocclusionisunchangedonadmission.An

openreduction,however,mayberequired.”2)“Absolutein-

dicationsfornon-surgicaltreatmentareintracapsularcondy-

larfractures,highcondylarfracturesclosetoorinvolvingthe

articularsurface,andfracturesingrowingchildren.”3)“Con-

servativetreatmentmayberequiredwhenthepatient’spast

medicalhistorydoesnotallowtheadministrationofgeneral

anesthesia.”4)“Openreductionisrecommendedforcon-

dylarfractures(especiallyononesideofbilateralfractures)

Treatment of extensive comminuted mandibular fracture using a reconstruction plate

139

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6. KazanjianVH.Anoutlineofthetreatmentofextensivecommi-nutedfracturesofthemandible:basedchieflyonexperiencegainedduringthelastwar.AmJOrthodOralSurg1942;28:B265-74.

7. EllisE3rd.TreatmentofmandibularanglefracturesusingtheAOreconstructionplate.JOralMaxillofacSurg1993;51:250-4.

8. ZachariadesN,MezitisM,MourouzisC,PapadakisD,SpanouA.Fracturesofthemandibularcondyle:areviewof466cases.Litera-turereview,reflectionsontreatmentandproposals.JCraniomaxil-lofacSurg2006;34:421-32.

9. MacLennanWD.Fracturesofthemandibularcondylarprocess.BrJOralSurg1969;7:31-9.

10. MarkerP,NielsenA,BastianHL.Fracturesofthemandibularcon-dyle.Part1:patternsofdistributionoftypesandcausesoffracturesin348patients.BrJOralMaxillofacSurg2000;38:417-21.

11. LindahlL.Condylarfracturesofthemandible.I.Classificationandrelationtoage,occlusion,andconcomitantinjuriesofteethandteeth-supportingstructures,andfracturesofthemandibularbody.IntJOralSurg1977;6:12-21.

12. ChoiKY,YangJD,ChungHY,ChoBC.CurrentconceptsinthemandibularcondylefracturemanagementpartII:openreductionversusclosedreduction.ArchPlastSurg2012;39:301-8.

13. DahlströmL,KahnbergKE,LindahlL.15yearsfollow-uponcon-dylarfractures.IntJOralMaxillofacSurg1989;18:18-23.

14. EllisE,ThrockmortonGS.Treatmentofmandibularcondylarpro-cessfractures:biologicalconsiderations.JOralMaxillofacSurg2005;63:115-34.

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16. PereiraCC,LetíciaDosSantosP,JardimEC,JúniorIR,ShinoharaEH,AraujoMM.Theuseof2.4-mmlockingplatesystemintreat-ingcomminutedmandibularfracturebyfirearm.CraniomaxillofacTraumaReconstr2012;5:91-6.

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butcouldnotbepracticallyachievedunderclosedreduction.

Finally,patientcooperationwasdifficulttoachievebecause

ofhispsychologicalstate.Fromthesereasons,theoraland

maxilla-facialsurgeryteamconcludedthatthiscomminuted

mandibularfracturewasan indicationforopenreduction

andinternalfixation.InthereportbySmithandTeenier5,a

partiallyedentulousstatewithoutstableocclusionwasasug-

gestedindicationforopenreductionandinternalfixation,and

earlymouthopeningexercisesafteropenreductionandinter-

nalfixationareessentialforTMJrehabilitation.Inthiscase,

openreductionandinternalfixationwithreconstructionanda

shortperiodofmaxillomandibularfixationwerethetreatment

ofchoice.Consideringthelimitationsofthisonecaseandthe

shortfollow-upperiod,wesuggestthatopenreductionand

internalfixationwithareconstructionplatecanbeasatisfac-

torytreatmentoptioninextensivecomminutedmandibular

fracturewithbilateralcondylarfractures.

Conflict of Interest

Nopotentialconflictofinterestrelevanttothisarticlewas

reported.

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3. LiZ,LiZB.Clinicalcharacteristicsand treatmentofmultiplesitecomminutedmandible fractures. JCraniomaxillofacSurg2011;39:296-9.