CLINICAL STUDY
Resorbable Plates for the Fixation of Isolated Mandibular Angle Fracture Rong-tao Yang, PhD, DDS, Kun Lv, PhD, DDS, Hai-hua Zhou, PhD, DDS, Zhi Li, PhD, DDS, and Zu-bing Li, PhD, DDS Purpose: This study was designed to evaluate the results in isolated mandibular angle fractures treated with resorbable plates and to summarize experiences of the application of resorbable plates. Patients and Methods: Ten patients (6 men and 4 women) with isolated displaced mandibular angle fracture were included in this case series. Open reduction by intraoral or extraoral approach was performed, and the fractures were fixed using single or dual resorbable plates. Postoperatively, follow-up was undertaken to evaluate the fracture healing and the degradation of resorbable plates. Results: All the fractures healed without complications during the follow-up period. No screw or plate fractured during the surgery, no dislocation of the fracture segment after the fixation by resorbable plates, and no foreign body reaction related with resorbable plates were observed. Conclusions: With proper indication, resorbable plates are suitable for the fixation of isolated mandibular angle fractures. Single or dual resorbable plates by intraoral or extraoral approach can be individualized on the basis of the patients' condition. Key Words: Resorbable plates, mandibular angle fractures, open reduction and internal fixation (J Craniofac Surg 2015;26: 447–448)
M
andibular angle is one of the most common sites of mandibular fractures. For isolated mandibular angle fracture, single titanium miniplate on the external oblique ridge (Champy technique) of the mandible has become the preferred treatment method.1 Meanwhile, other techniques including dual miniplates, locking screw plates, three-dimensional plates, lag screws, and so forth are popular treatment options for mandibular angle fractures.2 In general, the optimal treatment of mandibular fractures is still controversial. With the development of biodegradable materials, resorbable plates provide a new choice for the fixation of mandibular angle fractures. Compared with titanium plates, the advantages of resorbable plates include gradual degradation in a few years, the potential to eliminate complications related with permanent titanium plates, From the State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) and Key Laboratory of Oral Biomedicine Ministry of Education, School & Hospital of Stomatology, Wuhan University, Wuhan, Hubei, China. Received June 25, 2014. Accepted for publication September 13, 2014. Address correspondence and reprint requests to Zu-bing Li, PhD, DDS, Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, 237# Luoyu Road, Wuhan City 430079, Hubei Province, People's Republic of China; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001349
and no need for an additional removal operation.3 However, owing to the high prices of resorbable plates and the lack of experiences in operating the instrument for resorbable plates, the wide application of resorbable plates in maxillofacial fractures is restricted in clinic. This study was designed to evaluate the results in isolated mandibular angle fractures treated with resorbable plates and to summarize experiences of the application of resorbable plates.
PATIENTS AND METHODS Resorbable plates (BioSorb FX 2.0; Linvatec Biomaterials Ltd, Tampere, Finland) were used in 10 isolated mandibular angle fractures, which were treated in the Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, China, from July 2012 to December 2013. Only single displaced mandibular angle fractures were included; nondisplaced fractures were not enrolled. There were 6 male and 4 female patients ranging in age from 15 to 55 years (mean age, 28.2 y). This study was approved by the ethics committee of Wuhan University. Of these patients, 5 patients were treated by intraoral open reduction and internal fixation using a 2.0-mm BioSorb FX resorbable plate, 3 patients were treated by intraoral open reduction and internal fixation using two 2.0-mm BioSorb FX resorbable plates with the assistance of transbuccal instrument, 1 patient was treated by extraoral open reduction and internal fixation using two 2.0-mm BioSorb FX resorbable plates, and 1 patient was treated by both intraoral and extraoral open reduction and internal fixation using two 2.0-mm BioSorb FX resorbable plates. In general, 5 of the 6 male patients used 2 plates, and 1 of the 4 male patients used 1 plate. Of all the patients, the impacted or partially erupted third molar in the fracture line was found in 9 patients. All these tooth were not extracted from the fracture site during the surgery. After the surgery, mouth rinsing with 0.1% of chlorhexidine twice a day during the first week, liquid diet and avoidance of clenching within 2 weeks, soft diet within 2 months, and regular follow-up were undertaken in all patients. Computed tomography scans were taken for evaluation of the fracture healing and the degradation of resorbable plates.
RESULTS The duration of follow-up ranged from 6 to 12 months. All the fractures healed without complications; facial nerve injuries, malocclusion, malunion, nonunion, and infection were not observed during the follow-up period. The patient's maximal mouth opening increased to a mean of 38.7 mm. No screw or plate fractured during the surgery, no dislocation of the fracture segment after the fixation by resorbable plates, and no foreign body reaction related with resorbable plates were observed during the follow-up.
DISCUSSION Resorbable plates and screws have been developed and applied in craniomaxillofacial surgery to avoid problems related with
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
447
Yang et al
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
the fixation of titanium plates. Although a variety of resorbable osteofixation system of different polymer compositions are currently available for craniomaxillofacial applications, we have exclusively used resorbable plates and screws constructed of self-reinforced polymers of D- and L-lactic acid with 30% of D-lactide and 70% of L-lactide (BioSorb FX 2.0; Linvatec Biomaterials Ltd, Tampere, Finland). It is reported that self-reinforced plates of this material are stronger than other commercially available resorbable plates.4 Whether resorbable plates are suitable for the fixation of mandibular angle fractures is still controversial. From a mechanical point of view, based on the computer model, Tams et al5 reported that resorbable plates are suitable for mandibular symphysis and body fractures but are not suitable for mandibular angle fractures. In another similar study, according to the three-dimensional finite element analysis of resorbable plates and titanium plates for the rigid fixation of mandibular angle fractures, Cox et al6 indicated that titanium fixation is more rigid than resorbable fixation. However, they also showed that resorbable plates provide sufficient stiffness to meet established norms for fracture immobility.6 Lee et al7 compared the use of dual resorbable plates and titanium miniplates for the fixation of mandibular fractures including 12 angle fractures; their results showed that the postoperative complications were minor in cases of mandibular fractures treated with resorbable plates, suggesting that resorbable plates have the same potential as titanium plates for successful use in the fixation of mandibular fractures. Bayat et al8 even considered that the use of a single resorbable plate for unilateral mandibular angle fractures is a reliable fixation technique with minor complications. In this study, single or dual resorbable plates were used for isolated mandibular angle fractures by intraoral or extraoral approach and have achieved good results. This adds weight to the limited existing publications and provides strong support for the wide use of resorbable plates in isolated mandibular angle fractures. In our experience, to use single resorbable plate or dual plates is feasible in both theory and practice; however, it should be chosen carefully after thoughtful considerations on some special factors as below. For smokers and alcoholics, dual plates are recommended, as alcohol abuse and smoking contributed to the development of postoperative complications.9 For male patients, the second plates should be considered, as the mandible in men is stronger than that in women, and the compliance of the male patients is not as high as that in female patients. If those high-risk individuals agree to cooperate with the treatment, single plate may also be an option. Fortunately, patients in this study had high compliance of the treatment; this also contributed to the good treatment effects. In our opinion, noncompliant patients have a high risk for complication in the treatment of mandibular angle fractures; in this case, resorbable plates should not be considered, because titanium plates are more rigid and recommended for the fixation. Single resorbable plate by intraoral approach should be positioned on the external oblique ridge (Champy line). If another plate is necessary, try and apply the transbuccal instrument first. However, because of the high manipulation accuracy requirement in both transbuccal instrument and the resorbable fixation devices, minor submandibular incision of less than 2 cm can be designed if it is too difficult to place the second plate with the application of transbuccal instrument. For displaced angle
448
fracture with serious soft tissue lacerations around the third molar region, extraoral approach is recommended. In this case, 1 plate should be positioned buccally on the external oblique ridge, and the other should be positioned on the inferior mandibular border. Whether to remove the third molar in the fracture line is also controversial. In this study, to ensure the stability of the reduction and to avoid displacement of the fracture segments, 9 third molars were not extracted from the fracture site. During the follow-up, no complication related with the third molar was noted. Even so, serious decayed teeth, periodontitis, periapical periodontitis, and tooth fractures are indications for extraction.10 With the development of biodegraded materials, we believe that resorbable plates would be the optimal option for maxillofacial fractures, even for mandibular fractures. In the current development stage, resorbable plates can be applied with a strict control of indications. For isolated mandibular angle fractures, resorbable plates are potential materials for substituting titanium plates.
CONCLUSIONS With proper indication, resorbable plates are suitable for the fixation of isolated mandibular angle fractures. Single or dual resorbable plates by intraoral or extraoral approach can be individualized on the basis of the patients' condition.
REFERENCES 1. Gear AJ, Apasova E, Schmitz JP, et al. Treatment modalities for mandibular angle fractures. J Oral Maxillofac Surg 2005;63:655–663 2. Ellis E III. Treatment methods for fractures of the mandibular angle. Int J Oral Maxillofac Surg 1999;28:243–252 3. Vazquez-Morales DE, Dyalram-Silverberg D, Lazow SK, et al. Treatment of mandible fractures using resorbable plates with a mean of 3 weeks maxillomandibular fixation: a prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2013;115:25–28 4. Ylikontiola L, Sundqvuist K, Sandor GK, et al. Self-reinforced bioresorbable poly-L/DL-lactide [SR-P(L/DL)LA] 70/30 miniplates and miniscrews are reliable for fixation of anterior mandibular fractures: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:312–317 5. Tams J, Otten B, van Loon JP, et al. A computer study of fracture mobility and strain on biodegradable plates used for fixation of mandibular fractures. J Oral Maxillofac Surg 1999;57:973–981 6. Cox T, Kohn MW, Impelluso T. Computerized analysis of resorbable polymer plates and screws for the rigid fixation of mandibular angle fractures. J Oral Maxillofac Surg 2003;61:481–487 7. Lee HB, Oh JS, Kim SG, et al. Comparison of titanium and biodegradable miniplates for fixation of mandibular fractures. J Oral Maxillofac Surg 2010;68:2065–2069 8. Bayat M, Garajei A, Ghorbani K, et al. Treatment of mandibular angle fractures using a single bioresorbable miniplate. J Oral Maxillofac Surg 2010;68:1573–1577 9. Paza AO, Abuabara A, Passeri LA. Analysis of 115 mandibular angle fractures. J Oral Maxillofac Surg 2008;66:73–76 10. Malanchuk VO, Kopchak AV. Risk factors for development of infection in patients with mandibular fractures located in the tooth-bearing area. J Craniomaxillofac Surg 2007;35:57–62
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Resorbable Plates for the Fixation of Isolated Mandibular Angle Fracture Rong-tao Yang, PhD, DDS, Kun Lv, PhD, DDS, Hai-hua Zhou, PhD, DDS, Zhi Li, PhD, DDS, and Zu-bing Li, PhD, DDS Purpose: This study was designed to evaluate the results in isolated mandibular angle fractures treated with resorbable plates and to summarize experiences of the application of resorbable plates. Patients and Methods: Ten patients (6 men and 4 women) with isolated displaced mandibular angle fracture were included in this case series. Open reduction by intraoral or extraoral approach was performed, and the fractures were fixed using single or dual resorbable plates. Postoperatively, follow-up was undertaken to evaluate the fracture healing and the degradation of resorbable plates. Results: All the fractures healed without complications during the follow-up period. No screw or plate fractured during the surgery, no dislocation of the fracture segment after the fixation by resorbable plates, and no foreign body reaction related with resorbable plates were observed. Conclusions: With proper indication, resorbable plates are suitable for the fixation of isolated mandibular angle fractures. Single or dual resorbable plates by intraoral or extraoral approach can be individualized on the basis of the patients' condition. Key Words: Resorbable plates, mandibular angle fractures, open reduction and internal fixation (J Craniofac Surg 2015;26: 447–448)
M
andibular angle is one of the most common sites of mandibular fractures. For isolated mandibular angle fracture, single titanium miniplate on the external oblique ridge (Champy technique) of the mandible has become the preferred treatment method.1 Meanwhile, other techniques including dual miniplates, locking screw plates, three-dimensional plates, lag screws, and so forth are popular treatment options for mandibular angle fractures.2 In general, the optimal treatment of mandibular fractures is still controversial. With the development of biodegradable materials, resorbable plates provide a new choice for the fixation of mandibular angle fractures. Compared with titanium plates, the advantages of resorbable plates include gradual degradation in a few years, the potential to eliminate complications related with permanent titanium plates, From the State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) and Key Laboratory of Oral Biomedicine Ministry of Education, School & Hospital of Stomatology, Wuhan University, Wuhan, Hubei, China. Received June 25, 2014. Accepted for publication September 13, 2014. Address correspondence and reprint requests to Zu-bing Li, PhD, DDS, Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, 237# Luoyu Road, Wuhan City 430079, Hubei Province, People's Republic of China; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001349
and no need for an additional removal operation.3 However, owing to the high prices of resorbable plates and the lack of experiences in operating the instrument for resorbable plates, the wide application of resorbable plates in maxillofacial fractures is restricted in clinic. This study was designed to evaluate the results in isolated mandibular angle fractures treated with resorbable plates and to summarize experiences of the application of resorbable plates.
PATIENTS AND METHODS Resorbable plates (BioSorb FX 2.0; Linvatec Biomaterials Ltd, Tampere, Finland) were used in 10 isolated mandibular angle fractures, which were treated in the Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, Wuhan University, China, from July 2012 to December 2013. Only single displaced mandibular angle fractures were included; nondisplaced fractures were not enrolled. There were 6 male and 4 female patients ranging in age from 15 to 55 years (mean age, 28.2 y). This study was approved by the ethics committee of Wuhan University. Of these patients, 5 patients were treated by intraoral open reduction and internal fixation using a 2.0-mm BioSorb FX resorbable plate, 3 patients were treated by intraoral open reduction and internal fixation using two 2.0-mm BioSorb FX resorbable plates with the assistance of transbuccal instrument, 1 patient was treated by extraoral open reduction and internal fixation using two 2.0-mm BioSorb FX resorbable plates, and 1 patient was treated by both intraoral and extraoral open reduction and internal fixation using two 2.0-mm BioSorb FX resorbable plates. In general, 5 of the 6 male patients used 2 plates, and 1 of the 4 male patients used 1 plate. Of all the patients, the impacted or partially erupted third molar in the fracture line was found in 9 patients. All these tooth were not extracted from the fracture site during the surgery. After the surgery, mouth rinsing with 0.1% of chlorhexidine twice a day during the first week, liquid diet and avoidance of clenching within 2 weeks, soft diet within 2 months, and regular follow-up were undertaken in all patients. Computed tomography scans were taken for evaluation of the fracture healing and the degradation of resorbable plates.
RESULTS The duration of follow-up ranged from 6 to 12 months. All the fractures healed without complications; facial nerve injuries, malocclusion, malunion, nonunion, and infection were not observed during the follow-up period. The patient's maximal mouth opening increased to a mean of 38.7 mm. No screw or plate fractured during the surgery, no dislocation of the fracture segment after the fixation by resorbable plates, and no foreign body reaction related with resorbable plates were observed during the follow-up.
DISCUSSION Resorbable plates and screws have been developed and applied in craniomaxillofacial surgery to avoid problems related with
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
447
Yang et al
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
the fixation of titanium plates. Although a variety of resorbable osteofixation system of different polymer compositions are currently available for craniomaxillofacial applications, we have exclusively used resorbable plates and screws constructed of self-reinforced polymers of D- and L-lactic acid with 30% of D-lactide and 70% of L-lactide (BioSorb FX 2.0; Linvatec Biomaterials Ltd, Tampere, Finland). It is reported that self-reinforced plates of this material are stronger than other commercially available resorbable plates.4 Whether resorbable plates are suitable for the fixation of mandibular angle fractures is still controversial. From a mechanical point of view, based on the computer model, Tams et al5 reported that resorbable plates are suitable for mandibular symphysis and body fractures but are not suitable for mandibular angle fractures. In another similar study, according to the three-dimensional finite element analysis of resorbable plates and titanium plates for the rigid fixation of mandibular angle fractures, Cox et al6 indicated that titanium fixation is more rigid than resorbable fixation. However, they also showed that resorbable plates provide sufficient stiffness to meet established norms for fracture immobility.6 Lee et al7 compared the use of dual resorbable plates and titanium miniplates for the fixation of mandibular fractures including 12 angle fractures; their results showed that the postoperative complications were minor in cases of mandibular fractures treated with resorbable plates, suggesting that resorbable plates have the same potential as titanium plates for successful use in the fixation of mandibular fractures. Bayat et al8 even considered that the use of a single resorbable plate for unilateral mandibular angle fractures is a reliable fixation technique with minor complications. In this study, single or dual resorbable plates were used for isolated mandibular angle fractures by intraoral or extraoral approach and have achieved good results. This adds weight to the limited existing publications and provides strong support for the wide use of resorbable plates in isolated mandibular angle fractures. In our experience, to use single resorbable plate or dual plates is feasible in both theory and practice; however, it should be chosen carefully after thoughtful considerations on some special factors as below. For smokers and alcoholics, dual plates are recommended, as alcohol abuse and smoking contributed to the development of postoperative complications.9 For male patients, the second plates should be considered, as the mandible in men is stronger than that in women, and the compliance of the male patients is not as high as that in female patients. If those high-risk individuals agree to cooperate with the treatment, single plate may also be an option. Fortunately, patients in this study had high compliance of the treatment; this also contributed to the good treatment effects. In our opinion, noncompliant patients have a high risk for complication in the treatment of mandibular angle fractures; in this case, resorbable plates should not be considered, because titanium plates are more rigid and recommended for the fixation. Single resorbable plate by intraoral approach should be positioned on the external oblique ridge (Champy line). If another plate is necessary, try and apply the transbuccal instrument first. However, because of the high manipulation accuracy requirement in both transbuccal instrument and the resorbable fixation devices, minor submandibular incision of less than 2 cm can be designed if it is too difficult to place the second plate with the application of transbuccal instrument. For displaced angle
448
fracture with serious soft tissue lacerations around the third molar region, extraoral approach is recommended. In this case, 1 plate should be positioned buccally on the external oblique ridge, and the other should be positioned on the inferior mandibular border. Whether to remove the third molar in the fracture line is also controversial. In this study, to ensure the stability of the reduction and to avoid displacement of the fracture segments, 9 third molars were not extracted from the fracture site. During the follow-up, no complication related with the third molar was noted. Even so, serious decayed teeth, periodontitis, periapical periodontitis, and tooth fractures are indications for extraction.10 With the development of biodegraded materials, we believe that resorbable plates would be the optimal option for maxillofacial fractures, even for mandibular fractures. In the current development stage, resorbable plates can be applied with a strict control of indications. For isolated mandibular angle fractures, resorbable plates are potential materials for substituting titanium plates.
CONCLUSIONS With proper indication, resorbable plates are suitable for the fixation of isolated mandibular angle fractures. Single or dual resorbable plates by intraoral or extraoral approach can be individualized on the basis of the patients' condition.
REFERENCES 1. Gear AJ, Apasova E, Schmitz JP, et al. Treatment modalities for mandibular angle fractures. J Oral Maxillofac Surg 2005;63:655–663 2. Ellis E III. Treatment methods for fractures of the mandibular angle. Int J Oral Maxillofac Surg 1999;28:243–252 3. Vazquez-Morales DE, Dyalram-Silverberg D, Lazow SK, et al. Treatment of mandible fractures using resorbable plates with a mean of 3 weeks maxillomandibular fixation: a prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2013;115:25–28 4. Ylikontiola L, Sundqvuist K, Sandor GK, et al. Self-reinforced bioresorbable poly-L/DL-lactide [SR-P(L/DL)LA] 70/30 miniplates and miniscrews are reliable for fixation of anterior mandibular fractures: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:312–317 5. Tams J, Otten B, van Loon JP, et al. A computer study of fracture mobility and strain on biodegradable plates used for fixation of mandibular fractures. J Oral Maxillofac Surg 1999;57:973–981 6. Cox T, Kohn MW, Impelluso T. Computerized analysis of resorbable polymer plates and screws for the rigid fixation of mandibular angle fractures. J Oral Maxillofac Surg 2003;61:481–487 7. Lee HB, Oh JS, Kim SG, et al. Comparison of titanium and biodegradable miniplates for fixation of mandibular fractures. J Oral Maxillofac Surg 2010;68:2065–2069 8. Bayat M, Garajei A, Ghorbani K, et al. Treatment of mandibular angle fractures using a single bioresorbable miniplate. J Oral Maxillofac Surg 2010;68:1573–1577 9. Paza AO, Abuabara A, Passeri LA. Analysis of 115 mandibular angle fractures. J Oral Maxillofac Surg 2008;66:73–76 10. Malanchuk VO, Kopchak AV. Risk factors for development of infection in patients with mandibular fractures located in the tooth-bearing area. J Craniomaxillofac Surg 2007;35:57–62
© 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
