Received: 16 October 2011 Accepted: 7 March 2013 Available online 30 April 2013
Available online at
www.sciencedirect.com
Original article
Biangular fractures of the mandible Caracte´ristiques des fractures bi-angulaires de la mandibule M. Donadillea, N. Vidalb, B. Ellac, F. Siberchicota, N. Zwetyengab,*,d a Department of maxillofacial surgery, centre Franc¸ois-Xavier-Michelet, groupe hospitalier Pellegrin, place Ame´lie-Raba-Le´on, 33076 Bordeaux cedex, France b Department of maxillofacial, plastic and reconstructive surgery, universite´ de Bourgogne, centre hospitalier universitaire, boulevard de Lattre-de-Tassigny, 21000 Dijon, France c Department of ondontology and oral surgery, groupe hospitalier Pellegrin, place Ame´lie-Raba-Le´on, 33076 Bordeaux cedex, France d Research Unit EA 4268: intervention, innovation, imagery, engineering in health (I4S), place Saint-Jacques, 25030 Besanc¸on cedex, France
Summary
Re´sume´
Introduction. Bifocal fractures of the mandible often associate the angle and condyle or symphysis. Little data is available on biangular fractures. The authors had for aim to study their characteristics and to suggest an adapted management. Material and methods. We retrospectively reviewed the records of patients operated on for a biangular fracture from January 2005 to December 2009. The impact of a third molar was evaluated using Pell and Gregory’s and Shiller’s classifications. Results. Six hundred and forty patients underwent surgery for a mandibular fracture, seven of whom (1.1%) for biangular fractures. The patients’ mean age was 27.6 years. Patients were predominantly men (85.7%). Assaults or brawls were the most frequent etiology (85.7%). The mechanism was direct impact in every case. The inferior alveolar nerve was injured in 57.1% of cases. There was an impacted third molar in 71.4% of cases. Most of the time, a single miniplate was sufficient for each angle. Two cases of postoperative infection were noted. The mean follow-up was 52.2 months. The occlusion was restored in every case. Three patients presented with neurological sequels in the V3 area. Discussion. Biangular fractures are rare and present a high risk of infection and neurological sequels. The presence of a mesioangular impacted third molar seems to be a predisposing factor. The risk of neurological sequels requires performing surgery rapidly. ß 2013 Elsevier Masson SAS. All rights reserved.
Introduction. Les fractures bifocales mandibulaires associent souvent un trait symphysaire ou parasymphysaire et un trait angulaire. Peu de donne´es spe´cifiques sont disponibles sur les fractures biangulaires. Le but de cette e´tude e´tait de rapporter leurs caracte´ristiques et de proposer une prise en charge adapte´e. Patients et me´thodes. Nous avons e´tudie´ re´trospectivement les patients traite´s pour une fracture biangulaire entre janvier 2004 et de´cembre 2009. L’influence de la pre´sence d’une troisie`me molaire a e´te´ e´value´e au travers de deux classifications : celle de Pell et Gregory et celle de Shiller. Re´sultats. Six cent quarante patients ont e´te´ ope´re´s pour une fracture mandibulaire dont sept (1,1 %) pour une fracture biangulaire. L’aˆge moyen e´tait 27,6 ans avec une pre´dominance masculine (85,7 %). Rixes et agressions regroupaient 85,7 % des e´tiologies. Le me´canisme e´tait un choc direct dans tous les cas. Le nerf alve´olaire infe´rieur e´tait alte´re´ dans 57,1 % des cas. Une troisie`me molaire e´tait incluse dans 71,4 %. Ge´ne´ralement, une mini-plaque par angle e´tait suffisante. Deux infections postope´ratoires ont e´te´ note´es. Le suivi moyen e´tait de 52,2 mois. L’articule´ dentaire a e´te´ restaure´ dans tous les cas. Trois patients avaient des se´quelles sensitives dans le territoire du V3. Discussion. La fracture biangulaire est rare avec un risque e´leve´ d’infection et de se´quelles. La pre´sence d’une troisie`me molaire semble eˆtre un facteur favorisant. Le risque se´quellaire neurologique impose une intervention le plus rapidement possible. ß 2013 Elsevier Masson SAS. Tous droits re´serve´s.
Keywords: Mandible, Fracture, Impacted tooth, Molar
Mots cle´s : Mandibule, Fracture, Dent incluse, Molaire
* Corresponding author. e-mail: [email protected] 2213-6533/$ - see front matter ß 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.revsto.2013.03.004 Rev Stomatol Chir Maxillofac Chir Oral 2013;114:287-291
287
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Rev Stomatol Chir Maxillofac Chir Oral 2013;114:287-291
Introduction Traumas of the mandible are relatively common injuries and account for 24 to 50% of all cranial and maxillofacial trauma [1–3]. The angular region of the mandible is usually concerned by both single and multiple fractures. The mandibular angle is a weak transition zone between dentate and edentate regions. It is more prone to fractures than other areas of the mandibular bone. Angle fractures are frequently associated with impacted or partially erupted third molars [4–12]. Most bifocal mandibular fractures associate the angle and condyle or symphysis [2,3]. Biangular mandibular fractures are very rare and few specific studies have been made on this type of fracture [5]. The authors had for aim to report the outcome of patients operated on for a biangular mandibular fracture and to suggest a specific management.
Material and methods The medical records of patients operated on for a fracture of the mandible, between January 2004 and December 2009, were retrospectively reviewed. Patients with biangular fracture of the mandible were selected for inclusion in the study. The following data was recorded for each patient: age, sex, etiology, preoperative and postoperative occlusion, presence or absence of lower third molars, preoperative and postoperative status on the inferior alveolar nerve territory, preoperative and postoperative occlusion, treatment, postoperative complications, and sequels. Two classifications were used to determine the impact of mandibular third molar position on the incidence of fractures and complications.
Pell and Gregory classification The Pell and Gregory classification [6] (fig. 1) is based on coverage of the third molar by the anterior border of the ramus (horizontal position) (class I, class II, or class III), and the depth of inclusion (vertical position) relative to the adjacent tooth (position A, position B, or position C). Class 0 was the absence of a third molar: horizontal position: class I: the impacted third molar is situated anterior to the anterior border of the ramus, class II: the impacted third molar’s crown is half covered by the anterior border of the ramus, class III: the impacted third molar’s crown is fully covered by the anterior border of the ramus; vertical position: position A: the occlusal plane of the impacted third molar is at the same level as the occlusal plane of the second molar, position B: the occlusal plane of the impacted third molar is between the occlusal plane and the cervical line of the second molar,
288
Figure 1. Pell and Gregory’s classification: horizontal position (class I, class II and class III) and the depth of the impaction vertical position relative to the adjacent tooth (position A, position B, and position C). Class 0 indicated the absence of the third molar.
position C: the impacted third molar is below the cervical line of the second molar.
Shiller’s classification Shiller’s classification [7] was used to evaluate the relationship between the longitudinal axis of the impacted third molar and the longitudinal axis of the second molar (angulation of the third molar): vertical: angle from 0 to 108; mesioangular and distoangular: angle from 118 to 708; horizontal: more than 718. We searched the Medline database for reports published between 1979 and 2011 to compare our results with detailed published cases. The keywords used were: fracture of the mandible, fracture of the mandible angle, single fracture of the mandible, multiple fractures of the mandible, monofocal fracture of the mandible, multifocal fracture of the mandible, bifocal fracture of the mandible, comminuted fracture of the mandible, mandibular fracture, mandibular angle fracture, single mandibular fracture, multiple mandibular fractures, monofocal mandibular fracture, multifocal mandibular fracture, bifocal mandibular fracture, and comminuted mandibular fracture.
Surgical technique All surgical procedures were performed under general anesthesia. A nasogastric tube was placed before surgery. Intermaxillary screws were screwed into the maxilla and the mandible. First, an incision was made in the mucosa, and then subperiosteal dissection was performed down to the lower border of the mandible. The lower third molar was
Biangular fractures of the mandible
systematically removed when present. The site of the fracture was curetted and the fracture was reduced to obtain adequate occlusion. We used intermaxillary screws with interdental wires to maintain the dental occlusion while the plates were inserted. A combined transbuccal and intraoral approach was performed when necessary. Once occlusion was obtained one or two titanium miniplates (thickness: 1 mm) (Ortrautek TekkaW, Lyon; France) were bent and placed on the external oblique ridge of the mandible and fixed using self-threading screws (diameter 2.0 mm). The length of the plate and the number of holes were decided according to peroperative data. The same technique was used for the other side. Dental occlusion was controlled and the mucosa was sutured with absorbable stitches. All patients were given appropriate pre- and peroperative antibiotics: amoxicillin/clavulanic acid (3 g/day) or clindamycin (600 mg/day). Antibiotherapy, non-steroidal analgesics, and mouthwash were prescribed for seven postoperative days. The nasogastric tube was removed the day before the patient’s discharge, generally on the 5th day. Soft food ingestion was recommended for six weeks. Guidance elastics were used for three weeks to maintain occlusion. Functional therapy was recommended for 3 months, 15 days after surgery. Patients were followed-up regularly, on postoperative day 15 and 30, then every 3 months for 2 years. Plate removal was proposed after the sixth month.
Figure 2. Preoperative panoramic X-ray showing biangular fracture, the left and right third molars were respectively classified IIB/IIB (Pell and Gregory’s classification) and horizontal/mesioangular (Shiller’s classification).
Figure 3. Preoperative panoramic X-ray showing a biangular fracture. The patient’s third molars were removed 7 days before trauma.
Results During the study period, 640 patients were operated on for fracture of the mandible, 94 (14.7%) for condylar fracture alone, and 546 (85.3%) for extracondylar fracture (table I). In the extracondylar fracture group, there were 271 cases of
unifocal fractures, 43 of multifocal fractures, and 232 of bifocal fractures. Among the 232 cases of bifocal fractures, seven were biangular, corresponding to 1.1% of all fractures, and 3% of the bifocal fractures operated on (figs. 2, 3). All details are listed in Table I.
Table I Patient features. Patient
Age
Sex
Context
Alveolar nerve area (L/R)
Pell and Gregory (L/R)
Shiller (L/R)
Time (mn)
Complications
Follow-up (months)
1
18
M
Aggression
None
IIB/IIB
H/Me
90
None
(108)
2
21
M
Brawl
None
0/0
0/0
70
None
TMJ disorders (36)
?
LTF (5th day)
None
(48)
Infection
Bilateral hypoesthesia (48)
3
20
M
Brawl
Bilateral anesthesia
IB/IIB
Me/V
90
4
20
M
Fall from a beam
Bilateral anesthesia
IIB/IIB
H/Me
100
5
33
M
Aggression
Anesthesia/ hypoesthesia
IIB/IIIB
Me/Me
6
57
W
Aggression
Bilateral anesthesia
0/0
0/0
130
None
Anesthesia/ neuralgia (38)
7
24
M
Aggression
Bilateral hypoesthesia
IIC/IIB
Me/V
100
Infection
Bilateral hypoesthesia (35)
70
M: man; W: woman; Me: mesioangular; H: horizontal; V: vertical; Y: years; L: left; R: right; Mn: minutes; LTF: lost to follow-up.
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Figure 4. 3D-CT-scan showing the preoperative bilateral fracture of angle with open bite and impacted mandibular third molars.
The mean age of patients was 27.6 years (18–57 years). Six patients were men. The etiology was assault and/or brawl for six patients, occurring between 8:00 p.m. and 6:00 a.m., and in three cases during the weekend. The mechanism of the fracture was direct impact in every case. All of the patients had an anterior open bite (figs. 4, 5). Four patients had inferior alveolar nerve damage. Anesthesia was reported in five cases and hypoesthesia in three cases. A lower impacted third molar was present in ten of the 14 sites. One patient’s (no.2) third molars had been removed seven days before trauma. The Pell and Gregory classification was used for the ten hemimandibles with impacted third molars: seven sites were classified II and eight classified B. The IIB class was the most frequent (six angles out of 10). Shiller’s classification was also used for the ten hemimandibles with impacted third molars: six were classified mesioangular, two horizontal, and two vertical. The mean duration of the surgical procedure was 92.8 minutes (70 to 130 minutes). A single miniplate on each side was used for six patients. A combined transbuccal and intraoral approach was used in one
Figure 5. CT-Scan with sagittal views of bilateral fracture of the angles, with open bite and impacted mandibular third molars. Damage to the alveolar nerve was predictable.
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Rev Stomatol Chir Maxillofac Chir Oral 2013;114:287-291
Figure 6. postoperative panoramic X-ray showing osteosynthesis of biangular fracture, using two miniplates in each side.
case. One patient (no.7) had two miniplates placed on each side (fig. 6). There were postoperative complications in two patients. Two months after surgery, patient no.5 presented with pain and inflammation of the right side due to infection. Medical treatment was effective (analgesic, antibiotics, and corticosteroids). The second patient (no.7) had an infection of the right side at 1.5 months. The miniplate was removed and intermaxillary blockage was used for 15 days. A mandibular reconstruction plate was inserted after that. The postoperative phase was uneventful. One patient was lost to follow-up at the fifth postoperative day. The mean follow-up was 52.2 months (35–108 months). Occlusion was restored in all patients by the end of the study. One patient had TMJ disorders (pain, clicking) 2 months after the operation and physiotherapy did not give satisfactory results at 36 months. Three patients had neurologic sequels. Only two patients who were followed had no sequel. Only one specific study on biangular fracture was found in the literature [5].
Discussion Biangular fractures of the mandible are rare: it concerned 1.1% of all patients we operated on for mandibular fracture over a 6-year period. This frequency correlates to published data [1,4]. Paza et al. reported only one patient with bilateral angle fracture in 115 (0.8%) cases of angle fracture [1]. Boffano and Roccia reported eight patients out of 635 (1.2%) [5], and the highest percentage was reported by Thangavelu et al.: 4.1% (25 patients out of 600) [4]. Biangular mandibular fractures concern young men as reported in the literature on mandibular angle fracture [2,3,8,9,11]. Aggression and/or brawls are the predominant causes. Our percentage is high compared to literature data (ranging from 19 to 53%) [2,3,9,11]. Most traumas occur at night (after 8:00 p.m.). This type of fracture is attributable to habits, occupation, and natural aggressive tendencies. Biangular fractures usually occur, caused by direct trauma.
Biangular fractures of the mandible
Third molar impaction is associated with a high risk of fracture in case of trauma. An experimental study demonstrated that in cases of impacted molars, only 60% of the usual energy is required for bone fracture [10]. Mandible angle fractures are associated with impacted third molars in 30 to 73% of published cases [9,11,12]. Thagavelu et al. reported that patients with impacted third molars were three times more at risk for angle fracture. [4]. Boffano and Roccia found impacted third molars in all of their patients with biangular fracture of the mandible [5]. Two of our patients did not have impacted third molars. But the angles were weakened because of tooth removal in the first patient, and the second patient had a very thin mandible [4]. Most third impacted molars were classified in position IIB, according to Pell and Gregory’s classification [4]. This contrasts with other publications [7], which reported more in the C position [11,12]. Most reported molar positions were classified mesioangular [4]. Other authors [11,12] reported that the vertical position was a higher risk factor for mandibular angle fracture. Bone resorption is another risk factor [10]. This was the case for one of our patients who was edentulous. The global rate of reported postoperative complications in mandibular angle fracture ranges from 0 to 32% [2,8,13,15,16], correlating with our results (17%). Infections in angle fracture occur in 15 to 17% of patients [2–5]. But both of our patients with postoperative complications and the one reported by Boffano and Roccia [5] presented with infections. Biangular fracture seems to induce a high risk of infection. Half of our patients had neurological sequels, but there is no published data to compare with. These sequels can be explained by the instability of the biangular fracture. The suprahyoid muscles push down the anterior segment of the fracture and the posterior muscles (temporal, masseter, medial and lateral pterygoid muscles) elevate the posterior segment. This instability increases the displacement of the fracture and induces or aggravates nerve injury. Michelet et al. were the ones to report on osteosynthesis with miniaturized screwed plates in maxillofacial surgery in 1973 [14]. Applying the principle of osteosynthesis depends on the school, the surgeon’s habits, and the patient’s state [3,13–16]. The consensus is that miniplates should be associated with intermaxillary fixation using elastics or wires in multifocal fractures. The intraoral approach is the first-line method to avoid scars, when feasible. Using a single miniplate on the superior border of mandible is easy and reliable [2]. Biangular mandibular fractures are rare and unstable, and induce a high risk of infection. Two thirds of patients will have sequels. Neurological sequels are common. One of the predisposing factors seems to be mesioangular impacted third molars in position IIB. Our strategy is to systematically remove the lower third molar, insert one plate and screws for intermaxillary fixation. The operation should be performed as soon as possible because of the high rate of nerve injury. If possible a CT-scan must be performed before surgery to localize the mandibular nerve intramandibular path [17].
A prospective study should be made on the use of tacrolimusW to avoid or decrease neurological sequels in displaced fracture of the toothed part of the mandible [18]. Another study should be made on the use of plates specially adapted to this type of fracture.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
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[17]
[18]
Gassner R, Tuli T, Ha ¨chl O, Rudisch A, Ulmer H. Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 2003;31:51–61. Paza AO, Abuabara A, Passer LA. Analysis of 115 mandibular angle fractures. J Oral Maxillofac Surg 2008;66:73–6. Potter J, Ellis 3rd E. Treatment of mandibular angle fractures with a malleable noncompression miniplate. J Oral Maxillofac Surg 1999;57:288–92 [discussion: 292–3]. Thangavelu A, Yoganandha R, Vaidhyanathan A. Impact of impacted mandibular third molars in mandibular angle and condylar fractures. Int J Oral Maxillofac Surg 2010;39:136–9. Boffano P, Roccia F. Bilateral mandibular angle fractures: clinical considerations. J Craniofac Surg 2010;21:328–31. Pell G, Gregory B. Impacted mandibular third molars, classification and modified technique for removal. Dent Digest 1933; 39:330–8. Shiller WR. Positional changes in meso-angular impacted mandibular third molars during a year. J Am Dent Assoc 1979;99: 460–4. Ellis E, 3rd, Moos K, el-Attar A. Ten years of mandibular fractures: an analysis of 2137 cases. Oral Surg Oral Med Oral Pathol 1985;59:120–9. Subhashraj K. A study on the impact of mandibular third molar on angle fractures. J Oral Maxillofac Surg 2009;67:968–72. Reitzik M, Lownie JF, Cleaton-Jones P, Austin J. Experimental fractures of monkey mandibles. Int J Oral Surg 1978;7:100–3. Iida S, Hassfeld S, Reuther T, Nomura K, Mu ¨hling J. Relationship between the risk of angle fractures and the status of incompletely erupted mandibular third molars. J Craniomaxillofac Surg 2005;33:158–63. Ma’aita J, Alwrikat A. Is the mandibular third molar is a risk factor for mandibular angle fracture? Oral Surg Oral Med Oral Pathol Endo 2000;89:143–6. Passeri LA, Ellis E, Sinn DP. Complications of non rigid fixation of mandibular angle fractures. J Oral Maxillofac Surg 1993;51:382–4. Michelet FX, Deymes J, Dessus B. Osteosynthesis with miniaturized screwed plates in maxillofacial surgery. J Maxillofac Surg 1973;1:79–84. Fox AJ, Kellman RM. Mandibular angle fractures: two-miniplate fixation and complications. Arch Facial Plast Surg 2003;5:464–9. Levy F, Smith R, Odland RM, Marentette LJ. Monocortical miniplate fixation of mandibular angle fractures. Arch Otolaryngol Head Neck Surg 1991;11:149–54. Drikes S, Delcampe P, Sabin P, Lavis JF, Cordier G, Vacher C, et al. Scan study of the mandibular nerve intramandibular path. Rev Stomatol Chir maxillofac 2011;112:e5–10. Martin D, Pinsolle V, Merville P, Moreau K, Pelissier P, Baudet J. First case in the world of autoreplantation of limb associated with oral administration of an immunosuppressant agent (FK 506–TacrolimusW). Ann Chir Plast Esthet 2005;50:257–63.
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Available online at
www.sciencedirect.com
Original article
Biangular fractures of the mandible Caracte´ristiques des fractures bi-angulaires de la mandibule M. Donadillea, N. Vidalb, B. Ellac, F. Siberchicota, N. Zwetyengab,*,d a Department of maxillofacial surgery, centre Franc¸ois-Xavier-Michelet, groupe hospitalier Pellegrin, place Ame´lie-Raba-Le´on, 33076 Bordeaux cedex, France b Department of maxillofacial, plastic and reconstructive surgery, universite´ de Bourgogne, centre hospitalier universitaire, boulevard de Lattre-de-Tassigny, 21000 Dijon, France c Department of ondontology and oral surgery, groupe hospitalier Pellegrin, place Ame´lie-Raba-Le´on, 33076 Bordeaux cedex, France d Research Unit EA 4268: intervention, innovation, imagery, engineering in health (I4S), place Saint-Jacques, 25030 Besanc¸on cedex, France
Summary
Re´sume´
Introduction. Bifocal fractures of the mandible often associate the angle and condyle or symphysis. Little data is available on biangular fractures. The authors had for aim to study their characteristics and to suggest an adapted management. Material and methods. We retrospectively reviewed the records of patients operated on for a biangular fracture from January 2005 to December 2009. The impact of a third molar was evaluated using Pell and Gregory’s and Shiller’s classifications. Results. Six hundred and forty patients underwent surgery for a mandibular fracture, seven of whom (1.1%) for biangular fractures. The patients’ mean age was 27.6 years. Patients were predominantly men (85.7%). Assaults or brawls were the most frequent etiology (85.7%). The mechanism was direct impact in every case. The inferior alveolar nerve was injured in 57.1% of cases. There was an impacted third molar in 71.4% of cases. Most of the time, a single miniplate was sufficient for each angle. Two cases of postoperative infection were noted. The mean follow-up was 52.2 months. The occlusion was restored in every case. Three patients presented with neurological sequels in the V3 area. Discussion. Biangular fractures are rare and present a high risk of infection and neurological sequels. The presence of a mesioangular impacted third molar seems to be a predisposing factor. The risk of neurological sequels requires performing surgery rapidly. ß 2013 Elsevier Masson SAS. All rights reserved.
Introduction. Les fractures bifocales mandibulaires associent souvent un trait symphysaire ou parasymphysaire et un trait angulaire. Peu de donne´es spe´cifiques sont disponibles sur les fractures biangulaires. Le but de cette e´tude e´tait de rapporter leurs caracte´ristiques et de proposer une prise en charge adapte´e. Patients et me´thodes. Nous avons e´tudie´ re´trospectivement les patients traite´s pour une fracture biangulaire entre janvier 2004 et de´cembre 2009. L’influence de la pre´sence d’une troisie`me molaire a e´te´ e´value´e au travers de deux classifications : celle de Pell et Gregory et celle de Shiller. Re´sultats. Six cent quarante patients ont e´te´ ope´re´s pour une fracture mandibulaire dont sept (1,1 %) pour une fracture biangulaire. L’aˆge moyen e´tait 27,6 ans avec une pre´dominance masculine (85,7 %). Rixes et agressions regroupaient 85,7 % des e´tiologies. Le me´canisme e´tait un choc direct dans tous les cas. Le nerf alve´olaire infe´rieur e´tait alte´re´ dans 57,1 % des cas. Une troisie`me molaire e´tait incluse dans 71,4 %. Ge´ne´ralement, une mini-plaque par angle e´tait suffisante. Deux infections postope´ratoires ont e´te´ note´es. Le suivi moyen e´tait de 52,2 mois. L’articule´ dentaire a e´te´ restaure´ dans tous les cas. Trois patients avaient des se´quelles sensitives dans le territoire du V3. Discussion. La fracture biangulaire est rare avec un risque e´leve´ d’infection et de se´quelles. La pre´sence d’une troisie`me molaire semble eˆtre un facteur favorisant. Le risque se´quellaire neurologique impose une intervention le plus rapidement possible. ß 2013 Elsevier Masson SAS. Tous droits re´serve´s.
Keywords: Mandible, Fracture, Impacted tooth, Molar
Mots cle´s : Mandibule, Fracture, Dent incluse, Molaire
* Corresponding author. e-mail: [email protected] 2213-6533/$ - see front matter ß 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.revsto.2013.03.004 Rev Stomatol Chir Maxillofac Chir Oral 2013;114:287-291
287
M. Donadille et al.
Rev Stomatol Chir Maxillofac Chir Oral 2013;114:287-291
Introduction Traumas of the mandible are relatively common injuries and account for 24 to 50% of all cranial and maxillofacial trauma [1–3]. The angular region of the mandible is usually concerned by both single and multiple fractures. The mandibular angle is a weak transition zone between dentate and edentate regions. It is more prone to fractures than other areas of the mandibular bone. Angle fractures are frequently associated with impacted or partially erupted third molars [4–12]. Most bifocal mandibular fractures associate the angle and condyle or symphysis [2,3]. Biangular mandibular fractures are very rare and few specific studies have been made on this type of fracture [5]. The authors had for aim to report the outcome of patients operated on for a biangular mandibular fracture and to suggest a specific management.
Material and methods The medical records of patients operated on for a fracture of the mandible, between January 2004 and December 2009, were retrospectively reviewed. Patients with biangular fracture of the mandible were selected for inclusion in the study. The following data was recorded for each patient: age, sex, etiology, preoperative and postoperative occlusion, presence or absence of lower third molars, preoperative and postoperative status on the inferior alveolar nerve territory, preoperative and postoperative occlusion, treatment, postoperative complications, and sequels. Two classifications were used to determine the impact of mandibular third molar position on the incidence of fractures and complications.
Pell and Gregory classification The Pell and Gregory classification [6] (fig. 1) is based on coverage of the third molar by the anterior border of the ramus (horizontal position) (class I, class II, or class III), and the depth of inclusion (vertical position) relative to the adjacent tooth (position A, position B, or position C). Class 0 was the absence of a third molar: horizontal position: class I: the impacted third molar is situated anterior to the anterior border of the ramus, class II: the impacted third molar’s crown is half covered by the anterior border of the ramus, class III: the impacted third molar’s crown is fully covered by the anterior border of the ramus; vertical position: position A: the occlusal plane of the impacted third molar is at the same level as the occlusal plane of the second molar, position B: the occlusal plane of the impacted third molar is between the occlusal plane and the cervical line of the second molar,
288
Figure 1. Pell and Gregory’s classification: horizontal position (class I, class II and class III) and the depth of the impaction vertical position relative to the adjacent tooth (position A, position B, and position C). Class 0 indicated the absence of the third molar.
position C: the impacted third molar is below the cervical line of the second molar.
Shiller’s classification Shiller’s classification [7] was used to evaluate the relationship between the longitudinal axis of the impacted third molar and the longitudinal axis of the second molar (angulation of the third molar): vertical: angle from 0 to 108; mesioangular and distoangular: angle from 118 to 708; horizontal: more than 718. We searched the Medline database for reports published between 1979 and 2011 to compare our results with detailed published cases. The keywords used were: fracture of the mandible, fracture of the mandible angle, single fracture of the mandible, multiple fractures of the mandible, monofocal fracture of the mandible, multifocal fracture of the mandible, bifocal fracture of the mandible, comminuted fracture of the mandible, mandibular fracture, mandibular angle fracture, single mandibular fracture, multiple mandibular fractures, monofocal mandibular fracture, multifocal mandibular fracture, bifocal mandibular fracture, and comminuted mandibular fracture.
Surgical technique All surgical procedures were performed under general anesthesia. A nasogastric tube was placed before surgery. Intermaxillary screws were screwed into the maxilla and the mandible. First, an incision was made in the mucosa, and then subperiosteal dissection was performed down to the lower border of the mandible. The lower third molar was
Biangular fractures of the mandible
systematically removed when present. The site of the fracture was curetted and the fracture was reduced to obtain adequate occlusion. We used intermaxillary screws with interdental wires to maintain the dental occlusion while the plates were inserted. A combined transbuccal and intraoral approach was performed when necessary. Once occlusion was obtained one or two titanium miniplates (thickness: 1 mm) (Ortrautek TekkaW, Lyon; France) were bent and placed on the external oblique ridge of the mandible and fixed using self-threading screws (diameter 2.0 mm). The length of the plate and the number of holes were decided according to peroperative data. The same technique was used for the other side. Dental occlusion was controlled and the mucosa was sutured with absorbable stitches. All patients were given appropriate pre- and peroperative antibiotics: amoxicillin/clavulanic acid (3 g/day) or clindamycin (600 mg/day). Antibiotherapy, non-steroidal analgesics, and mouthwash were prescribed for seven postoperative days. The nasogastric tube was removed the day before the patient’s discharge, generally on the 5th day. Soft food ingestion was recommended for six weeks. Guidance elastics were used for three weeks to maintain occlusion. Functional therapy was recommended for 3 months, 15 days after surgery. Patients were followed-up regularly, on postoperative day 15 and 30, then every 3 months for 2 years. Plate removal was proposed after the sixth month.
Figure 2. Preoperative panoramic X-ray showing biangular fracture, the left and right third molars were respectively classified IIB/IIB (Pell and Gregory’s classification) and horizontal/mesioangular (Shiller’s classification).
Figure 3. Preoperative panoramic X-ray showing a biangular fracture. The patient’s third molars were removed 7 days before trauma.
Results During the study period, 640 patients were operated on for fracture of the mandible, 94 (14.7%) for condylar fracture alone, and 546 (85.3%) for extracondylar fracture (table I). In the extracondylar fracture group, there were 271 cases of
unifocal fractures, 43 of multifocal fractures, and 232 of bifocal fractures. Among the 232 cases of bifocal fractures, seven were biangular, corresponding to 1.1% of all fractures, and 3% of the bifocal fractures operated on (figs. 2, 3). All details are listed in Table I.
Table I Patient features. Patient
Age
Sex
Context
Alveolar nerve area (L/R)
Pell and Gregory (L/R)
Shiller (L/R)
Time (mn)
Complications
Follow-up (months)
1
18
M
Aggression
None
IIB/IIB
H/Me
90
None
(108)
2
21
M
Brawl
None
0/0
0/0
70
None
TMJ disorders (36)
?
LTF (5th day)
None
(48)
Infection
Bilateral hypoesthesia (48)
3
20
M
Brawl
Bilateral anesthesia
IB/IIB
Me/V
90
4
20
M
Fall from a beam
Bilateral anesthesia
IIB/IIB
H/Me
100
5
33
M
Aggression
Anesthesia/ hypoesthesia
IIB/IIIB
Me/Me
6
57
W
Aggression
Bilateral anesthesia
0/0
0/0
130
None
Anesthesia/ neuralgia (38)
7
24
M
Aggression
Bilateral hypoesthesia
IIC/IIB
Me/V
100
Infection
Bilateral hypoesthesia (35)
70
M: man; W: woman; Me: mesioangular; H: horizontal; V: vertical; Y: years; L: left; R: right; Mn: minutes; LTF: lost to follow-up.
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M. Donadille et al.
Figure 4. 3D-CT-scan showing the preoperative bilateral fracture of angle with open bite and impacted mandibular third molars.
The mean age of patients was 27.6 years (18–57 years). Six patients were men. The etiology was assault and/or brawl for six patients, occurring between 8:00 p.m. and 6:00 a.m., and in three cases during the weekend. The mechanism of the fracture was direct impact in every case. All of the patients had an anterior open bite (figs. 4, 5). Four patients had inferior alveolar nerve damage. Anesthesia was reported in five cases and hypoesthesia in three cases. A lower impacted third molar was present in ten of the 14 sites. One patient’s (no.2) third molars had been removed seven days before trauma. The Pell and Gregory classification was used for the ten hemimandibles with impacted third molars: seven sites were classified II and eight classified B. The IIB class was the most frequent (six angles out of 10). Shiller’s classification was also used for the ten hemimandibles with impacted third molars: six were classified mesioangular, two horizontal, and two vertical. The mean duration of the surgical procedure was 92.8 minutes (70 to 130 minutes). A single miniplate on each side was used for six patients. A combined transbuccal and intraoral approach was used in one
Figure 5. CT-Scan with sagittal views of bilateral fracture of the angles, with open bite and impacted mandibular third molars. Damage to the alveolar nerve was predictable.
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Figure 6. postoperative panoramic X-ray showing osteosynthesis of biangular fracture, using two miniplates in each side.
case. One patient (no.7) had two miniplates placed on each side (fig. 6). There were postoperative complications in two patients. Two months after surgery, patient no.5 presented with pain and inflammation of the right side due to infection. Medical treatment was effective (analgesic, antibiotics, and corticosteroids). The second patient (no.7) had an infection of the right side at 1.5 months. The miniplate was removed and intermaxillary blockage was used for 15 days. A mandibular reconstruction plate was inserted after that. The postoperative phase was uneventful. One patient was lost to follow-up at the fifth postoperative day. The mean follow-up was 52.2 months (35–108 months). Occlusion was restored in all patients by the end of the study. One patient had TMJ disorders (pain, clicking) 2 months after the operation and physiotherapy did not give satisfactory results at 36 months. Three patients had neurologic sequels. Only two patients who were followed had no sequel. Only one specific study on biangular fracture was found in the literature [5].
Discussion Biangular fractures of the mandible are rare: it concerned 1.1% of all patients we operated on for mandibular fracture over a 6-year period. This frequency correlates to published data [1,4]. Paza et al. reported only one patient with bilateral angle fracture in 115 (0.8%) cases of angle fracture [1]. Boffano and Roccia reported eight patients out of 635 (1.2%) [5], and the highest percentage was reported by Thangavelu et al.: 4.1% (25 patients out of 600) [4]. Biangular mandibular fractures concern young men as reported in the literature on mandibular angle fracture [2,3,8,9,11]. Aggression and/or brawls are the predominant causes. Our percentage is high compared to literature data (ranging from 19 to 53%) [2,3,9,11]. Most traumas occur at night (after 8:00 p.m.). This type of fracture is attributable to habits, occupation, and natural aggressive tendencies. Biangular fractures usually occur, caused by direct trauma.
Biangular fractures of the mandible
Third molar impaction is associated with a high risk of fracture in case of trauma. An experimental study demonstrated that in cases of impacted molars, only 60% of the usual energy is required for bone fracture [10]. Mandible angle fractures are associated with impacted third molars in 30 to 73% of published cases [9,11,12]. Thagavelu et al. reported that patients with impacted third molars were three times more at risk for angle fracture. [4]. Boffano and Roccia found impacted third molars in all of their patients with biangular fracture of the mandible [5]. Two of our patients did not have impacted third molars. But the angles were weakened because of tooth removal in the first patient, and the second patient had a very thin mandible [4]. Most third impacted molars were classified in position IIB, according to Pell and Gregory’s classification [4]. This contrasts with other publications [7], which reported more in the C position [11,12]. Most reported molar positions were classified mesioangular [4]. Other authors [11,12] reported that the vertical position was a higher risk factor for mandibular angle fracture. Bone resorption is another risk factor [10]. This was the case for one of our patients who was edentulous. The global rate of reported postoperative complications in mandibular angle fracture ranges from 0 to 32% [2,8,13,15,16], correlating with our results (17%). Infections in angle fracture occur in 15 to 17% of patients [2–5]. But both of our patients with postoperative complications and the one reported by Boffano and Roccia [5] presented with infections. Biangular fracture seems to induce a high risk of infection. Half of our patients had neurological sequels, but there is no published data to compare with. These sequels can be explained by the instability of the biangular fracture. The suprahyoid muscles push down the anterior segment of the fracture and the posterior muscles (temporal, masseter, medial and lateral pterygoid muscles) elevate the posterior segment. This instability increases the displacement of the fracture and induces or aggravates nerve injury. Michelet et al. were the ones to report on osteosynthesis with miniaturized screwed plates in maxillofacial surgery in 1973 [14]. Applying the principle of osteosynthesis depends on the school, the surgeon’s habits, and the patient’s state [3,13–16]. The consensus is that miniplates should be associated with intermaxillary fixation using elastics or wires in multifocal fractures. The intraoral approach is the first-line method to avoid scars, when feasible. Using a single miniplate on the superior border of mandible is easy and reliable [2]. Biangular mandibular fractures are rare and unstable, and induce a high risk of infection. Two thirds of patients will have sequels. Neurological sequels are common. One of the predisposing factors seems to be mesioangular impacted third molars in position IIB. Our strategy is to systematically remove the lower third molar, insert one plate and screws for intermaxillary fixation. The operation should be performed as soon as possible because of the high rate of nerve injury. If possible a CT-scan must be performed before surgery to localize the mandibular nerve intramandibular path [17].
A prospective study should be made on the use of tacrolimusW to avoid or decrease neurological sequels in displaced fracture of the toothed part of the mandible [18]. Another study should be made on the use of plates specially adapted to this type of fracture.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
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