Open reduction of mandibular fracture without maxillomandibular fixation: retrospective study

Chung-Hyun Lee; Chul-Hwan Kim

doi:10.5125/jkaoms.2011.37.4.255

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Lee and Kim: Open reduction of mandibular fracture without maxillomandibular fixation: retrospective study

Original Article

J Korean Assoc Oral Maxillofac Surg 2011;37(4):255-263.

Published online: 7 January 2011

DOI: https://doi.org/10.5125/jkaoms.2011.37.4.255

Open reduction of mandibular fracture without maxillomandibular fixation: retrospective study

Chung-Hyun Lee, Chul-Hwan Kim

Department of Oral and Maxillofacial Surgery, College of Dentistry, Dankook University, Choenan, Korea

Chul-Hwan Kim Department of Oral and Maxillofacial Surgery, College of Dentistry, Dankook University San #29 Anseodong, Choenan, 330-714, Korea TEL: +82-41-550-1996 FAX: +82-41-551-8988 E-mail: kimchoms@dankook.ac.kr

Received 12 April 201122 July 2011 Accepted 25 July 2011

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.

Abstract

Introduction

Maxillomandibular fixation (MMF) is essential before surgery under general anesthesia in maxillofacial trauma patients. MMF is usedbasically to reconstruct the occlusion and occlusal stability to recover the facial shape and oral functions. The arch bar and wire is a traditional method for MMF, but it can not only bring pressure to the periodontal ligaments and teeth but also cause a penetrating injury to the surgeons.

Materials and Methods

In this study, 198 patients with an open reduction using a manual reduction without MMF from September 2005 to May 2010 in Dankook University Dental Hospital were subjected to a followup evaluation during the postoperative 4 months periods. This study evaluated the incidence of complications according to the condition of the patient (gender, age), the state of bony union of the fracture sites and a numeric ratingscale evaluation for postoperative pain scoring.

Results

The complications were classified into major and minor according to the seriousness, and the major complication rate was as low as 2.02%. Only 2 cases of re-operations (1.01%) were encountered. In the classification according to the fracture line, plate fracture was observed in both cases of mandibular symphysis fracture, and angle fractures and loosening of two screws were noted in the case of mandibular angle fracture.
The complication rate was similar regardless of gender and age.
The degree of bony union was satisfactory, and the complication rate was reduced as the bony union improved.
More patients complained of pain as the operation time was increased.

Conclusion

The use of MMF is not always necessary if a skilled assistant is provided to help manually reduce the fracture site. Compared to otherstudies of mandibular fracture surgery using MMF, the complication rate was similar using only manual reduction and the patients' discomfort was reduced without MMF.

Keywords: Mandibular fracture, Maxillomandibular fixation, Postoperative complication

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Fig. 1.

Open reduction of mandibular symphysis fracture using manual reduction without arch bar. A. Preoperative occlusion B. Preoperative computed tomography, C. Intraoperative photograph showing repair of fracture, D. Postoperative radiograp after fixation.

Fig. 2.

Plate fracture in panorama radiograph.

Fig. 3.

A case of delayed union after operation. A. Delayed union in panorama radiograph after 4 months, B. Partially bony union after 1 year without re-operation.

Fig. 4.

Re-operation in a case of osteomyelitis. A. Panorama radiograph after 3 months, B. Re-operation by using reconstruction plate.

Table 1.

Patient characteristics included in this study

Variables	No. of patients (%)
Male/female	146/52
Mean age (range)	32.3 (15–69)
Mechanism of fracture
Assault	44 (22.2)
Motor vehicle accident	34 (17.2)
Fall	76 (38.4)
Sports	17 (8.6)
Work	16 (8.1)
Miscellaneous	11 (5.6)
Outcome of teeth in fracture line
Teeth along fracture line	49 (24.7)
Impacted teeth along fracture line	66 (33.3)
Delay to surgery (after 3 days)	60 (30.3)

Table 2.

Patient distribution according to fracture types

Fracture type	No. of patients (%)
Unilateral subcondyle	16 (8.1)
Subcondyle and symphysis	28 (14.1)
Subcondyle and angle	10 (5.1)
Unilateral body	8 (4.0)
Body and angle	7 (3.5)
Body and symphysis	8 (4.0)
Bilateral body	4 (2.0)
Unilateral angle	43 (21.7)
Angle and symphysis	35 (17.7)
Bilateral angle	8 (4.0)
Symphysis	31 (15.7)
Total	198 (100.0)

Table 3.

Fracture line distribution according to fracture sites

Fracture site	No. of fracture Line (%)
Symphysis	102 (34.0)
Body	31 (10.3)
Angle	113 (37.7)
Subcondyle	54 (18.0)
Total	300 (100.0)

Table 4.

Kawai classification according to bone healing pattern

Kawai Classification
Grade 1: No radiograhic changes
Grade 2: Bone resorption was observed at the fracture site
Grade 3: External or internal callus formation (Osteogenesis)
Grade 4: Bony union was observed

Table 5.

Definition of superficial surgical site infection in CDC

CDC definition of superficial surgical site infection

Infection occurs within 30 days of procedure

Involves only skin or subcutaneous tissue around the incision and at least one of the following:

Purulent drainage from the superficial incision
Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision
At least one of the following signs or symptoms of infection: pain or tenderness, localised swelling, redness, or heat and superficial incision is deliberately opened by surgeon, unless culture of incision is negative

CDC: Centers for Disease Control)

Table 6.

Patient distribution according to complications

Complication (n=22)	No. of patients	Re-operation case
Normal result	176	−
Wound dehiscence	4	−
Infection	5	−
Trismus	3	−
Malocclusion	3	−
Screw loosening	1	−
Plate fracture	2	−
Osteomyelitis	2	1
Delayed union	1	−
Nonunion	1	1
Total	198	2

Table 7.

Complication rate according to gender

Gender	No. of patients (%)	Complication (%)	P value
Male	146 (73.7)	17 (11.6)	0.689
Female	52 (26.3)	5 (9.6)

Table 8.

Complication rate according to age

Age (yr)	No. of patients (%)	Complication (%)	P value
11–20	46 (23.2)	2 (4.3)
21–30	66 (33.3)	6 (9.1)
31–40	34 (17.2)	4 (11.8)
41–50	24 (12.1)	4 (16.7)	0.271
51–60	17 (8.6)	4 (23.5)
61–70	11 (5.6)	2 (18.2)
Total	198 (100.0)	22 (11.1)

Table 9.

Plate & screw distribution and grade∗ based on radiographic examination according to fracture site

Fracture site	Total plates	Total screws	No. of plate fracture	No. of screw loosening	Grade	Complication (%)
Symphysis	202	949	1	0	3.84±0.39	5 (4.9)
Body	59	284	0	0	3.68±0.79	4 (12.9)
Angle	214	884	1	2	3.87±0.41	9 (8)
Subcondyle	101	391	0	0	3.80±0.45	4 (7.4)
Total	576	2508	2	2	3.83±0.47	22 (7.3)

grade∗: Kawai classification according to bone healing pattern. Data is presented by means±SD.

Table 10.

Correlations of grade∗, time to surgery, OP time, NRS with complication

Spearman test		Grade∗	Time to surgery	OP time	NRS
Spearman test		Grade∗	Time to surgery	OP time	Immediate post-OP	Discharge
Complication	Correlation efficient (r)	−0.249	−0.114	0.033	0.035	0.048
Complication	P value	0	0.094	0.623	0.603	0.481

(OP: operation, NRS: numeric rating scale)

grade∗: Kawai classification according to bone healing pattern.

Table 11.

Complication rate according to time to repair, OP time, NRS

Fracture type	Time to surgery (day)	OP time (min)	NRS		Complication (%)
Fracture type	Time to surgery (day)	OP time (min)	Immediate post-OP	Discharge	Complication (%)
Unilateral subcondyle	2.63±1.96	79.06±23.96	6.81±0.98	1.63±1.26	1 (6.3)
Subcondyle and symphysis	3.18±1.72	104.11±34.45	6.57±1.32	2.43±1.20	4 (14.3)
Subcondyle and angle	3.50±2.17	137.70±16.15	6.40±1.90	2.10±0.74	1 (10.0)
Unilateral body	3.00±2.73	60.63±14.50	6.38±1.19	2.25±1.04	1 (12.5)
Body and angle	2.86±2.12	78.57±16.00	6.29±1.98	2.14±0.69	2 (28.6)
Body and symphysis	2.38±0.74	60.25±21.19	6.38±0.52	2.38±0.52	0 (0.0)
Bilateral body	1.75±0.96	75.00±15.81	6.75±0.96	1.75±0.50	1 (25.0)
Unilateral angle	2.51±1.42	44.02±17.10	5.42±1.26	1.33±0.57	5 (11.6)
Angle and symphysis	2.31±1.66	65.34±10.60	5.63±0.84	1.69±1.05	5 (14.3)
Bilateral angle	2.88±2.36	131.88±13.35	5.38±1.60	1.50±0.53	1 (12.5)
Symphysis	2.90±1.68	36.94±14.53	5.23±1.15	1.58±0.96	1 (3.2)
Total	2.72±1.74	69.46±35.60	5.88±1.32	1.77±0.98	22 (11.1)

(OP: operation, NRS: numeric rating scale)

Data is presented by means±SD.

Table 12.

Correlations of grade∗, time to surgery, NRS with OP time

Spearman test		Grade∗	Time to surgery	NRS
Spearman test		Grade∗	Time to surgery	Immediate post-OP	Discharge
OP time	Correlation efficient (r)	−0.093	0.066	0.283	0.199
OP time	P value	0.172	0.335	0.000	0.003

(NRS: numeric rating scale, OP: operation)

grade∗: Kawai classification according to bone healing pattern.

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