Stomatologija, Baltic Dental and Maxillofacial Journal, 2016, Vol. 18, No. 2 39
Management of maxillofacial fractures within three years of empirical findings
Marijus Leketas*, Evelina Vedlugaitė*, Ričardas Kubilius*
SCIENTIFIC ARTICLES
SUMMaRy
Objectives. To investigate which treatment of maxillofacial fractures is more effective and what type of complications is the most common after observed treatment. The second aim is to explore relationship between treated facial bone fractures and temporomandibular joint (TMJ) pathology.
Material and Methods. Cases with TMJ pathology in Lithuanian University of Health Sci-ences (LUHS) in the Department of Maxillofacial Surgery (MS) during 2012-2014 were analysed to research the occurrence of TMJ disorders after facial bone fracture treatment. Moreover, the clinical data of patients that were treated in LUHS in the Department of MS during 2012-2014 was collected and analysed.
Results. Male patients had higher fracture ratio (zygomatic and maxillary – 84%, mandibu-lar – 89.72%). Complications occurred in 6% of the patients in a zygomatic and maxillary frac-tures group, mainly as an infraorbital nerve injury. Closed reduction and indirect fixation were performed for mandibular patients 49.7%. The ratio of complications for mandibular fractures was 6.1%. There were complications in group with the open reduction and direct fixation (24.2%, mostly osteomyelitis), when in the closed reduction and indirect fixation group (42.4%, mostly bone healing complications). There were no patients with TMJ pathology as a complication after facial bone fracture treatment.
Conclusions. Fractures treatment technique differs in all cases because of individual charac-teristics and treatment variations. In the open reduction and direct fixation group complications occurred in fewer cases than in the closed reduction and indirect fixation group. Well-timed facial bone fracture treatment leads to non-occurrence of TMJ complications.
Key words: fracture fixation, postoperative complications, mandibular fractures, maxillary fractures, zygomatic fractures, temporomandibular joint disorders.
SCIENTIFIC aRTICLESStomatologija, Baltic Dental and Maxillofacial Journal, 18: 39-50, 2016
*Department Maxillofacial Surgery, Lithuanian University of Health Sciences, Lithuania
Address correspondence to Marijus Leketas, Department of Maxillofacial Surgery, Medical Academy, Lithuanian University of Health Sciences, Eivenių g. 2, Kaunas LT-50028, Lithuania.E-mail address: [email protected]
INTRODUCTION
Facial fractures are treated by open reduction and closed reduction techniques. The fracture area is im-mobilized with intermaxillary fixation or other tech-niques, using screws, plates in order to achieve faster bone healing (1). There are various techniques for fracture treatment but there is no clearly established specific treatment best suited in each case. According to scientific publications open reduction and direct fixation has benefits such as quickly restored chewing function, optimal reposition, and faster rehabilitation. Closed reduction and indirect fixation procedure is
less traumatic, more protecting blood vessels and fracture area, less expensive, followed by a shorter hospitalization time of the patient (2). The purpose of this study is to find out which fracture treatment method is more effective.
The main goals of this research are to evaluate the effectiveness of the fracture treatment techniques, find out which technique leads to lower complications ratio, and verify the temporomandibular joint (TMJ) disorders occurrence after applied fracture treatment. Scientific articles are reviewed on this topic, research of mostly applied techniques was done, and complica-tions incidence rate was investigated. As well as the task is to analyze the data of the patients that were treated for facial fractures and for TMJ pathology separately in the Department of Maxillofacial Surgery in Lithuanian University of Health Sciences (LUHS).
40 Stomatologija, Baltic Dental and Maxillofacial Journal, 2016, Vol. 18, No. 2
Analysis of fracture cases data was selected on the aspects of chosen treatment method, the ensuing com-plications, and further treatment of complications. Analysis of clinical cases with temporomandibular joint disorder diagnosis was investigated to verify if they had facial bone fracture in the case history. The results from literature review and clinical data are compared.
MaTERIaL aND METHODS
Clinical data of 192 patients with temporoman-dibular joint disorders (TMD) during 2012-2014 years in LUHS Maxillofacial Surgery Department was collected. Main aspect of anamnesis was trauma in maxillofacial region and its treatment. Furthermore DC-TMJ exam form (3) had to be filled to evaluate clinical symptoms of each case. All patients had TMJ symptoms.
Moreover clinical data about maxillofacial frac-tures in LUHS Maxillofacial Surgery Department during 2012-2014 years was collected, focusing on fracture localisation, treatment, complication type and rate, treatment after complication. Patients were selected if they had facial bone fracture treatment in the Department of Maxillofacial Surgery in Lithu-anian University of Health Sciences from 2012 to 2014. Maxillary and zygomatic fractures appeared to 298 patients, mandibular fractures for 559 patients, multiple fractures – 28 patients. Complication oc-currence type and rate was explored, complications occurrence reliance from fracture localisation, type and intervention was analysed. Interventions analysis after complications was performed too. Data was systematized, quantitative records analysis was done with records statistical analysis program IBM SPSS 19v. Proof of statistical significance was checked with Fisher criterion. Result was considered as statistically significant if p<0.05.
When clinical analysis was fulfilled, literature review was performed through the search of PubMed, Google Scholar databases, with purpose to compare our results of clinical analysis with the results re-ceived from literature review. The keywords used for search were "maxillofacial fractures", "zygomatic fracture", "mandibular fracture", "open reduction”, "closed reduction", "temporomandibular joint”, "temporomandibular disorders”, "craniomandibular disorders". The search was restricted to the published date from 1 January 2008 to 31 December 2014. Through the search 2735 articles were found and analysed if they confirmed the topic about advantages and disadvantages of closed reduction and external fixation, open reduction and internal fixation, or com-
plications occurrence rates, 34 articles were found and included (Figure).
RESULTS
156 patients who complained about TMJ prob-lems were investigated. Mean age value was 25.3 +/-1.2 and 84% of patients were female. Only 2 pa-tients noted the history of facial trauma, especially in mandibular region. One 26 years male patient is professional boxer. He had no history of facial bone fracture but experienced mandibular trauma during boxing once in a while. After mandibular trauma patient experiences the pain in left temporomandibu-lar joint region both at rest and active mandibular movements. When the patient takes nonsteroidal anti-inflammatory drugs, the symptoms disappear till the next mandibular trauma.
Another patient is 22 years female patient with clicking and recurrent pain in temporomandibular joint region on the right. The symptoms started two years ago after mandibular trauma appeared dur-ing traffic accident. The patient complained about contusion in facial area without maxillofacial bone fracture.
From all patients there was no case of maxillofa-cial fracture although trauma in maxillofacial region was the most emphasized aspect in this survey.
Moreover clinical data of 933 patients with maxillofacial bone fracture cases from 2012 to 2014 who were treated in LUHS Maxillofacial Surgery Department was analysed. Maxillary and zygomatic fractures occurred in 298 cases (48 were rejected because of information shortage), mandible fractures in 559 cases (14 were rejected because of informa-tion shortage), and multiple fractures in 28 cases (information was rejected because of wide informa-tion dispersion).
Results showed that maxillary and zygomatic fractures occurence by gender was 84% (210 males) and 16% (40 females). Operative treatment (open reduction only, combination of open reduction and direct fixation) was the most frequent. Conservative methods (closed reduction only or combination of closed reduction and indirect fixation) were used less (Table 1).
In the cases of maxillary or zygomatic bone frac-tures, complications occurred for 6% of the patients. The most frequent complications were infraorbital nerve injuries (Table 2).
The analysis of treatment strategies after com-plication showed that in the cases where infraorbital nerve lesions appear, pharmacological medicament infusion, neurolysis, and physiotherapy or rest re-
M. Leketas, E. Vedlugaitė, R. Kubilius SCIENTIFIC ARTICLES
Stomatologija, Baltic Dental and Maxillofacial Journal, 2016, Vol. 18, No. 2 41
SCIENTIFIC ARTICLES M. Leketas, E. Vedlugaitė, R. Kubilius
When complications occurrence rate (in the cases where different interventions were performed) of zy-gomaticomaxillary complex was analysed, the results showed that complications occurrence dispersion has no statistical significant results (Fischer test P=0.625).
Statistical analysis of patients with mandibular fractures showed that mandibular fractures appear more frequent for male patients 89.72 % (489 males)
gime is used the most. If the complication was facial nerve injury, pharmacological medicament infusion was used. When the bone regeneration complication occurred, wire, screw or plate removal, physiother-apy, treatment with pharmacological medicament is performed. If the complication was osteomyelitis, antibiotic therapy, incision with drainage, and se-questrectomy was performed.
Fig. Flowchart of systematic review and its stages
42 Stomatologija, Baltic Dental and Maxillofacial Journal, 2016, Vol. 18, No. 2
than female patients (10.28%, n=56). Mandibular bilateral (40.9%, n=223) and angle (29.4%, n=160) fractures occurred the most frequently (see Table 3). In the cases of bilateral mandible fractures angle and body fractures occurred the most frequently. As well as bilateral body fractures (7.3%) and condylar process and body (9%) fractures occurred quite fre-quently (Table 3).
In most mandibular fracture cases chosen frac-ture treatment method was closed reduction and indirect fixation (n=271, 49.7%), and open reduction and direct fixation (38.2%) (Table 4).
When analysis of complications occurrence fre-quency was performed, the results showed that the cases where closed reduction and indirect fixation were done complications occurrence rate was higher (5.2%) than in the cases where open reduction and direct fixation were performed (3.8%). The results were statistically significant (Fisher test P<0,001) (Table 4).
Complications occurrence rate is 6.1% (n=33) (see Table 5). In most cases complications are bone regeneration complication (n=13, 2.4%) and osteo-myelitis (n=12, 2.2%) (Table 6).
After bone regeneration complication, chosen treatment was open reduction and internal fixation (5 patients), closed reduction and external fixation
(3 patients), pharmacological medicament infusion (3 patients), wire, screw, plate removal (1 patient), condilectomy (1 patient). Chosen treatment after osteomyelitis complication was pharmacological medicament infusion (8 patients), closed reduction and external fixation (2 patients), open reduction and direct fixation (1 patient) and sequestrectomy (1 patient). In the cases of phlegmone pharmacological medicament infusion (2 cases), incision and drainage (2 cases), indirect fixation (1 case) and physiotherapy (1 case) was performed. When the complication was abscess, incision and drainage was performed. In the case of periostitis incision, incision with drain-age, and pharmacological medicament infusion was performed. There was no case of TMJ pathology as a complication.
When analysis of complication occurrence de-pendence of fracture localisation was performed, the results showed that complications occurred mostly in these cases where condylar fractures, mandible body and ramus fractures were seen. The results were sta-tistically significant (Fisher test P=0.006) (Table 5).
Moreover when complications occurrence de-pendency of performed interventions was analysed, complication occurrence between different interven-tions showed statistically significant results. (Fisher test p=0.024) (Table 6).
M. Leketas, E. Vedlugaitė, R. Kubilius SCIENTIFIC ARTICLES
Table 1. Interventions dispersion in zygomaticomaxillary complex
Intervention Frequency PercentageOpen reduction 140 56.0Open reduction and direct fixation 5 2.0Closed reduction and indirect fixation
55 22.0
Closed reduction 9 3.6Clinical inspection 14 5.6Neurolysis 3 1.2Closed reduction and external fixation
21 8.4
Wire, screw, plate removal 3 1.2All in 250 100.0
Table 2. Complications type dispersion in zygomaticomaxil-lary complex. Complications occurrence dispersion has no statistical significant results (Fischer test P=0.625)
Complication Frequency PercentageInfraorbital nerve injury 10 4.0Facial nerve injury 2 .8Bone regeneration complication 2 .8
Osteomyelitis 1 .4All in 15 6.0
Table 3. Mandible fracture localisation
Intervention Frequency PercentageAngle 160 29.4Bilateral Bilateral angle Angle and condyle Angle and condylar process Angle and body Body and condylar process Angle and ramus Body and ramus Bilateral condylar process Condylar process and body Body and coronoid process Ramus and coronoid process Bilateral body Body and alveolar process
22362783112644921401
40.91.10.41.315.20.20.24.80.79.00.40.27.30.2
Condyle 3 .6Condylar process 53 9.7Symphysis and parasymphysis 21 3.9Body 48 8.8Multiple 15 2.8
Ramus 13 2.4Alveolar process 7 1.3Coronoid process 2 .4All in 545 100.0
Stomatologija, Baltic Dental and Maxillofacial Journal, 2016, Vol. 18, No. 2 43
SCIENTIFIC ARTICLES M. Leketas, E. Vedlugaitė, R. Kubilius
In the fracture cases where open reduction and direct fixation was performed, there was no-ticed higher occurrence of osteomyelitis. In cases where closed reduction and indirect fixation was performed, higher oc-currence of bone regen-eration complications was noticed.
Literature review was performed (Table 7); the analysis showed that most articles of this subject are published from India (8 of 34) and China (7 of 34). All in all in our study 34 articles were used. Mostly ar-ticles about mandibular fractures are published, and usual study object is the treatment results of mandibular condyle fractures (15 of 34). The amount of analysed pa-tients varies from 6 to 2986 patients. A total of 11428 patients’ informa-tion was analysed.
In zygomatic frac-tures open reduction and direct fixation (50.6-73.8%) is used more than closed reduction and indi-rect fixation (9.4-27.3%). Conservative treatment is chosen in 1.7-10.3% of cases. In the treatment of mandibular condyle fractures usually open re-duction and direct fixation was chosen (11 of 15 ar-ticles about the treatment of mandibular condyle fractures).
In zygomatic frac-ture cases where open reduction treatment was performed hypoesthesia, diplopia, mouth opening limitation, infection, he-
Table 4. Complication occurrence in dependence on the intervention peformed in mandibular region. The results were statistically significant (Fisher test P<0,001).
Complications TotalNot occurred Occurred
Intervention Open reduction Frequency 37 1 38% 97.4% 2.6% 100.0%
Incision and drainage Frequency 0 7 7% .0% 100.0% 100.0%
Open reduction and direct fixation
Frequency 200 8 208
% 96.2% 3.8% 100.0%Clinical inspection Frequency 8 1 9
% 88.9% 11.1% 100.0%Teeth removal Frequency 7 0 7
% 100.0% .0% 100.0%Wire, screw, plate removal Frequency 3 2 5
% 60.0% 40.0% 100.0%Closed reduction and indi-rect fixation
Frequency 257 14 271
% 94.8% 5.2% 100.0%Total Frequency 512 33 545
% 93.9% 6.1% 100.0%
Table 5. Complication occurrence in dependence on the fracture localisation in mandibular region. The results were statistically significant (Fisher test P=0.006).
Complication occurrence TotalNot occurred Occurred
Angle Frequency 150 10 160% 93,8% 6.3% 100.0%
Bilateral Frequency 214 9 223% 96.0% 4.0% 100.0%
Condyle Frequency 2 1 3% 66.7% 33.3% 100.0%
Condylar process Frequency 52 1 53% 98.1% 1.9% 100.0%
Symphysis and parasymphysis Frequency 21 0 21% 100.0% .0% 100.0%
Body Frequency 38 10 48% 79.2% 20.8% 100.0%
Multiple Frequency 14 1 15% 93.3% 6.7% 100.0%
Ramus Frequency 12 1 13% 92.3% 7.7% 100.0%
Alveolar process Frequency 7 0 7% 100.0% .0% 100.0%
Coronoid process Frequency 2 0 2% 100.0% .0% 100.0%
Total Frequency 512 33 545% 93.9% 6.1% 100.0%
44 Stomatologija, Baltic Dental and Maxillofacial Journal, 2016, Vol. 18, No. 2
M. Leketas, E. Vedlugaitė, R. Kubilius SCIENTIFIC ARTICLES
matoma complications occurred the most, occurrence rate was 19.1%.
In the mandibular fracture cases complication oc-currence rates vary from non-occurrence to 28.53%. The most frequent complications in open reduction cases were sensory complications, wound dehiscence, infection.
There are lots of articles (13 of 34) about post-operative TMJ complications after fractures. In most cases TMJ complications, such as TMJ dysfunction, stiffness, functional restrictions (4 articles), TMJ clicking (3 articles), and pain in TMJ area (2 articles) occurred.
DISCUSSION
The results showed that higher tendency of facial bone fractures exists between male patients (84%), and the same high results are in other studies (4, 5). In mandible fracture cases the most frequent fracture localisation is bilateral fracture and angle fracture (6).
In this study complication occurrence rate was low (6%) while after literature review results showed that complications occurrence ratio varies from non-occurrence to 28.53% (7-16). In zygomatic group complications occurrence ratio varies from non-occurrence to 19,1% (9).
The results of our retrospective analysis showed that in zygomatic and maxillary fractures cases the most common complications were infraorbital nerve injuries. In the mandible fractures cases bone regeneration complication and osteomyelitis. After literature review it was clear that in other studies the most common complication was wound - healing disturbancies, nerve trauma, infection and functional impairment (9, 15).
Complications occurrence rate in mandible fracture cases was higher where closed reduction and indirect fixation was performed; the most fre-quent complication was bone fracture regeneration complication. In our research the most frequent
complication in the cases where open reduction and direct fixation was performed was osteomyelitis. In other studies it is stated that more complications occur where open reduction and direct fixation is performed, and the most frequent complication is nerve injuries and infections (2). Mostly in surgically treated fractures the most frequent complications are infection, wound healing disturbancies, nerve inju-ries, osteosynthesis failure, osteomyelitis, occlusal disharmony, TMJ complications (7, 8, 11, 13-15, 18-30). This kind of research causes uncertainty on the superiority of open reduction and direct fixation method. But still there are publications where the most frequent treatment method was closed reduc-tion (59.52%), and postoperative complications, such as infection, irregular occlusion, TMJ dysfunctions and face asymmetry, occurrence rate was 10.31%. When infection appeared, treatment was applied us-ing antibiotic therapy. When irregular disturbances appeared, mostly reoperation or orthodontic treatment was offered. Temporomandibular joint disturbances were treated by physiotherapy. Face asymmetry was left without treatment (31).
In condylar or subcondylar fracture group correct anatomical position of the fragments was achieved more in operative group (32) and in closed reduction group TMJ dysfunction complications are observed (40). But there are publications where despite the surgical treatment poor anatomical reduction is clini-cally seen (33). In condylar or subcondylar fracture group mouth opening complications, occlusion dis-turbancies, TMJ complications such as pain, crepi-tation are observed (19, 20, 22, 26, 29, 30, 32-34). Condylar and subcondylar fractures are often treated endoscopically, and complications after this treatment are infection, fixation failure, temporary facial nerve complication, “Frey” syndrome. In our research com-plications after condylar and subcondylar fractures appeared in 2 of 56 cases, and there are cases when complications did not occur at all or occur just for temporary period (17, 35-37).
Table 6. Complications occurrence dependency of performed intervention in mandibular region. The results were statistically significant (Fisher test p=0.024).
Submandibular abscess
Osteomyelitis Bone regeneration complication
Periostitis Phlegmone Total
Open reduction 0 0 1 0 0 1Incision and drainage 0 4 0 0 3 7Open reduction and direct fixation 0 6 1 0 1 8Clinical inspection 0 0 1 0 0 1Wire, screw, plate removal 0 0 2 0 0 2Closed reduction and indirect fixation 1 2 8 1 2 14Total 1 12 13 1 6 33
Stomatologija, Baltic Dental and Maxillofacial Journal, 2016, Vol. 18, No. 2 45
Stud
yC
ount
rySa
mpl
eFr
actu
res t
reat
men
tM
ain
findi
ngs.
Com
plic
atio
ns o
ccur
renc
eK
. Hw
ang,
et
al. 2
011,
(9
)
Kor
eaZy
gom
atic
frac
ture
s in
469
case
sA
n op
en re
duct
ion
was
per
form
ed in
73.
8% (3
46
case
s), c
lose
d re
duct
ion
in 2
4.5%
(115
cas
es),
and
cons
erva
tive
treat
men
t in
only
1.7
%.
The
post
oper
ativ
e co
mpl
icat
ion
rate
occ
urre
d in
88
case
s (19
.1%
) fro
m
461
case
s ope
rate
d: h
ypes
thes
ia (5
0 ca
ses,
56.8
%),
dipl
opia
(15
case
s, 17
.0%
), lim
itatio
n of
mou
th o
peni
ng o
r clo
sure
(11
case
s, 12
.5%
), in
fect
ion
(6.8
%),
and
hem
atom
a (4
.5%
).R.
A.
Kam
ath,
et
al. 2
012,
(2
1)
Indi
a95
pat
ient
s (31
6 fa
cial
frac
ture
s):
42 zy
gom
atic
omax
illar
y co
mpl
ex
fract
ures
, 53
(83
fract
ures
) with
co
ncom
itant
man
dibu
lar f
ract
ures
. 11
onl
y th
e mid
face
.
92 c
ases
wer
e tre
ated
with
ope
n re
duct
ion
and
inte
rnal
fix
atio
n (O
RIF)
, and
3 c
ases
wer
e m
anag
ed c
onse
rva-
tivel
y.
The
mos
t fre
quen
t com
plic
atio
ns w
ere
infe
ctio
n an
d oc
clus
al d
isha
r-m
ony
(6 c
ases
eac
h) fo
llow
ing
oper
ativ
e in
terv
entio
n. 3
cas
es e
ach
of
resi
dual
swel
ling
and
nerv
e pa
rest
hesi
a w
ere
obse
rved
. Res
idua
l sca
rs
resu
lted
in 4
cas
es a
nd w
ound
deh
isce
nce
in 2
pat
ient
s.The
ove
rall
com
plic
atio
n ra
te in
stud
y w
as 2
5.26
%.
E.G
. Sal
en-
tijn,
et a
l. 20
13, (
27)
The
Net
her-
land
s
A re
trosp
ectiv
e st
udy
of 2
78
patie
nts w
ith m
idfa
cial
frac
ture
sO
pen
redu
ctio
n an
d di
rect
fixa
tion.
In to
tal 2
92 p
late
s an
d 12
09 sc
rew
s wer
e us
ed.
Com
plic
atio
ns c
onsi
sted
mai
nly
of su
bopt
imal
frac
ture
redu
ctio
n (2
1 pa
tient
), te
mpo
rary
par
aest
hesi
a of
the
infr
aorb
ital n
erve
(10
patie
nts)
, w
ound
infe
ctio
n (9
pat
ient
s).
R S
ee-
man
n, e
t al
. 201
0,
(15)
Aus
tria
322
with
335
surg
ical
ly tr
eate
d m
andi
bula
r ang
le fr
actu
res
95 fr
actu
res t
reat
ed w
ith 1
min
ipla
te, 1
70 w
ith 2
min
i-pl
ates
, 70
with
oth
er o
steos
ynth
esis
conc
epts.
Succ
essf
ul tr
eatm
ent o
ccur
red
in 9
3.69
% o
f fra
ctur
es w
ith 1
ope
n re
duct
ion
and
in 6
.31%
with
2 o
pen
redu
ctio
ns. W
ound
-hea
ling
dis-
turb
ance
(51
patie
nt),
infe
ctio
n (3
3), a
nd o
steo
synt
hesi
s fai
lure
(19)
. 71
.47%
(238
) wer
e co
mpl
etel
y fr
ee o
f com
plic
atio
ns.
V. S
ingh
, et
al.
2010
, (3
2)
Indi
a40
pat
ient
s with
subc
ondy
lar
frac
ture
s of t
he m
andi
ble
wer
e ev
alua
ted
Clos
ed re
duct
ion-
22
patie
nts,
open
redu
ctio
n- 1
8 pa
tient
sC
orre
ct p
ositi
on o
f the
frag
men
ts w
as a
chie
ved
sign
ifica
ntly
mor
e ac
cura
tely
in th
e op
erat
ive
grou
p. R
egar
ding
mou
th o
peni
ng/la
tera
l ex
curs
ion/
prot
rusi
on, s
igni
fican
t diff
eren
ces w
ere
obse
rved
bet
wee
n bo
th g
roup
s (op
en 3
9.6/
12.5
/5.9
mm
vs c
lose
d 33
.5/9
.8/4
.1 m
m).
The
visu
al a
nalo
g sc
orin
g re
veal
ed si
gnifi
cant
diff
eren
ce w
ith le
ss p
ain
in
the
oper
ativ
e tre
atm
ent g
roup
(1.1
ope
n vs
5.2
clo
sed)
. B
. van
den
B
ergh
, et
al. 2
011,
(2
7)
The
Net
her-
land
s
A to
tal o
f 426
man
dibu
lar f
rac-
ture
line
s wer
e id
entifi
ed.
213
dent
ate
patie
nts:
29
treat
ed w
ith in
term
axill
ary
fixat
ion
(IM
F), 9
9- I
MF
com
bine
d w
ith o
steo
syn-
thes
is, 7
9- IM
F on
ly p
er-o
pera
tivel
y to
mak
e O
RIF
po
ssib
le. 1
2 ed
entu
lous
pat
ient
s: 3
- with
Gun
ning
sp
lints
, 9 b
y O
RIF
60 (2
6.7%
) pat
ient
s pre
sent
ed w
ith c
ompl
icat
ions
, inc
ludi
ng (t
rans
ient
) hy
pose
nsib
ility
of t
he li
p an
d ch
in (3
4 pa
tient
s), d
ysoc
clus
ion
(15
pa-
tient
s), i
nfec
ted
oste
osyn
thes
is m
ater
ial (
6 pa
tient
s) a
nd te
mpo
rom
an-
dibu
lar d
ysfu
nctio
n (5
pat
ient
s).
S. C
. Le
uin,
et
al. 2
010,
(4
0)
USA
164
man
dibu
lar f
ract
ures
: 83-
con-
dyla
r or s
ubco
ndyl
ar (C
/SC)
fra
ctur
es. C
onco
mita
nt fr
actu
res
for 3
8 of
the 8
3 C/
SC ca
ses.
26 p
atie
nts w
ere
man
aged
med
ical
ly. 5
6 pa
tient
s un
derw
ent c
lose
d re
duct
ion
with
IMF
for a
n av
erag
e of
25.
7 da
ys (r
ange
, 15-
43 d
ays)
. 1 p
atie
nt u
nder
wen
t an
ope
n su
rgic
al re
duct
ion.
45 p
atie
nts w
ho c
ompl
eted
the
ques
tionn
aire
exp
erie
nced
tem
poro
man
-di
bula
r joi
nt (T
MJ)
dys
func
tion
afte
r tre
atm
ent:
6 (1
3.3%
) mild
, and
24
(53.
3%) s
ever
e. F
emal
es h
ave
mor
e se
vere
dys
func
tion
than
do
mal
es.
V. S
ingh
, et
al.
2012
, (3
8)
Indi
a10
38 p
atie
nts c
ases
with
max
il-lo
faci
al in
jurie
s wer
e an
alys
edO
RIF
was
per
form
ed in
72.
83%
of c
ases
, and
con
serv
-at
ive
man
agem
ent f
or 2
2.73
%, a
nd 2
.5%
pat
ient
s wer
e tre
ated
by
circ
um-m
andi
bula
r wiri
ng.
Ther
e w
as n
o in
fect
ion,
non
-uni
on, m
al u
nion
, or a
ny fu
nctio
nal d
is-
abili
ty re
porte
d in
the
patie
nts w
ho re
ceiv
ed IM
F fo
r 4-6
wee
ks. M
outh
op
enin
g w
as n
orm
al in
all
patie
nts.
TMJ s
tiffn
ess w
as d
urin
g fir
st w
eek
of a
fter r
elea
sing
IMF.
It c
omes
nor
mal
afte
r a w
eek
with
phy
siot
hera
-py
.J.
Shi,
et
al. 2
014,
(3
3)
Chi
na83
cas
es w
ith 1
59 m
andi
bula
r an
d co
ndyl
ar fr
actu
res s
ites
wer
e in
clud
ed in
the
treat
men
t an
alys
is.
Clos
ed tr
eatm
ent w
as p
erfo
rmed
in 2
2 co
ndyl
ar
proc
ess f
ract
ures
(28.
6%),
open
redu
ctio
n- fo
r 55
cond
ylar
pro
cess
frac
ture
s (71
.4%
).
Func
tiona
l TM
J eva
luat
ion
show
ed th
at o
vera
ll pa
tient
satis
fact
ion
rate
w
as 9
6.4%
. 6 p
atie
nts h
ad d
evia
tion
of m
andi
bula
r mov
emen
t, an
d al
l of
them
had
con
dyla
r fra
ctur
es. C
licki
ng in
the
TMJ w
as n
oted
at 2
si
tes a
nd p
ain
in 3
site
s; h
owev
er, t
here
was
no
sign
ifica
nt d
iffer
ence
be
twee
n th
e co
nser
vativ
e tre
atm
ent a
nd th
e su
rger
y gr
oup.
Tabl
e 7.
Mai
n ch
arac
teris
tics a
nd fi
ndin
gs o
f rev
iew
ed st
udie
s (co
ntin
ued
on n
ext p
age)
SCIENTIFIC ARTICLES M. Leketas, E. Vedlugaitė, R. Kubilius
46 Stomatologija, Baltic Dental and Maxillofacial Journal, 2016, Vol. 18, No. 2
Stud
yC
ount
rySa
mpl
eFr
actu
res t
reat
men
tM
ain
findi
ngs.
Com
plic
atio
ns o
ccur
renc
eT.
Esk
itas-
ciog
lu, e
t al
. 201
3,
(7)
Turk
ey75
3 m
andi
bula
r fra
ctur
e pa
tient
s. A
ll ca
ses h
ad a
tota
l of
109
0 fr
actu
res,
the
mos
t co
mm
on w
as th
e pa
rasy
mph
ysis
(2
8.6%
) fra
ctur
e.
For 2
5 (3
.3%
) pat
ient
s with
non
-disp
lace
d fra
ctur
e,
sym
ptom
atic
trea
tmen
t was
app
lied.
Clo
sed
redu
c-tio
n w
as p
erfo
rmed
in 2
80 (3
7.2%
), os
teos
ynth
esis
by O
RIF
for 4
03 (5
3.5%
); fo
r 134
of t
hese
- clo
sed
redu
ctio
n to
o.
61 (8
.1%
) pat
ient
s sh
owed
pos
tope
rativ
e co
mpl
icat
ions
: occ
lusi
on
diso
rder
, pla
te e
xpos
ition
, inf
ectio
n, s
enso
ry c
ompl
icat
ions
, ope
ning
at
the
muc
osal
sut
ures
, and
TM
J dy
sfun
ctio
n. T
here
was
no
com
-pl
icat
ion
for p
atie
nts
who
wer
e tre
ated
con
serv
ativ
ely.
The
low
est
com
plic
atio
n ra
tes
wer
e fo
r pat
ient
s w
ho h
ad c
lose
d re
duct
ion
alon
e (9
/280
) and
the
high
est i
n pa
tient
s w
ho h
ad b
oth
open
and
clo
sed
redu
ctio
n (3
0/13
4).
J.L.
Muñ
ante
-C
árde
nas,
et a
l. 20
10,
(24)
Bra
zil
2986
med
ical
reco
rds f
acia
l tra
uma
The
cons
erva
tive
treat
men
t was
use
d in
51%
of c
ases
, an
d 49
% re
ceiv
ed su
rgic
al tr
eatm
ent.
Post
oper
ativ
e co
mpl
icat
ions
iden
tified
for 5
pat
ient
s. F
rom
55
surg
i-ca
lly tr
eate
d ca
ses,
5 (9
%) h
ad p
osto
pera
tive
com
plic
atio
ns s
uch
as
surg
ical
wou
nd d
ehis
cenc
e (1
), fa
cial
par
esth
esia
(3),
infe
ctio
n du
e to
loss
of m
ater
ial fi
(1).
Com
plic
atio
ns re
late
d to
TM
J an
kylo
sis
and
faci
al a
sym
met
ry w
ere
not i
dent
ified
. Aut
hors
bel
ieve
that
it
was
ach
ieve
d by
ear
ly m
obili
zatio
n of
the
TMJ
and
inte
nsiv
e ph
ysi-
othe
rapy
.T.
Kan
no,
et a
l. 20
14,
(39)
Japa
n12
com
min
uted
man
dibu
lar
frac
ture
s with
a lo
w-p
rofil
e lo
ckin
g m
andi
bula
r rec
onst
ruc-
tion
plat
e
Ana
tom
ical
redu
ctio
n of
the
com
min
uted
segm
ents
re-
esta
blish
ed th
e m
andi
bula
r ske
leto
n in
stab
le o
cclu
sion
with
rigi
d IM
F vi
a ex
traor
al (3
3.3%
), in
traor
al (5
0%),
or c
ombi
ned
(16.
7%) a
ppro
ache
s.
Imm
edia
te fu
nctio
nal r
ecov
ery
was
ach
ieve
d. S
ound
bon
e he
alin
g ac
hiev
ed fo
r all
patie
nts,
no
com
plic
atio
ns w
ith a
mea
n fo
llow
-up
of
16.3
mon
ths.
Pre
oper
ativ
e ne
urol
ogic
al a
sses
smen
t sho
wed
par
es-
thes
ia o
f man
dibu
lar a
lveo
lar-
men
tal n
erve
in 8
cas
es (6
7%),
and
rem
aine
d af
ter s
urge
ry. I
n so
me
patie
nts,
a re
duce
d m
outh
-ope
ning
an
d lim
itatio
ns in
late
ral e
xcur
sion
wer
e no
ted
for 1
mon
th p
osto
p-er
ativ
ely.
¬¬V.
Pr
ade,
et
al. 2
014,
(3
5)
Fran
ce22
pat
ient
s (25
man
dibu
lar
cond
yle
frac
ture
s)Th
e ch
osen
trea
tmen
t was
end
osco
pica
lly a
ssist
ed
surg
ical
trea
tmen
tTh
e co
mpl
icat
ions
wer
e: in
fect
ion
(3),
fixat
ion
failu
re w
ith g
ood
con-
solid
atio
n(1)
; for
com
bine
d ap
proa
ches
: tem
pora
ry fa
cial
pal
sy(2
) and
2
case
s of F
rey
synd
rom
e.
J. S.
Sc
henk
el,
et a
l. 20
14,
(14)
Aus
tria
45 p
atie
nts w
ith c
omm
inut
ed
man
dibu
lar f
ract
ures
ORI
F us
ing
an in
traor
al a
ppro
ach
was
per
form
edEx
celle
nt p
osto
pera
tive
resu
lts w
ere
seen
in 8
4% (3
8 pa
tient
s). P
ost-
oper
ativ
e co
mpl
icat
ions
wer
e se
en in
16%
(n=7
). W
ound
deh
isce
nce
(7%
[n =
3])
, ost
eom
yelit
is (7
% [n
= 3
]), a
bsce
ss (4
% [n
= 2
]), b
one
necr
osis
(2%
[n =
1])
, non
occl
usio
n (2
%[n
= 1]
).V.
Sing
h, e
t al
. 201
3,
(29)
Indi
a40
pat
ient
s with
an
man
dibu
lar
angl
e fr
actu
re
All
patie
nts h
ad a
com
bina
tion
of O
RIF
and
max
il-lo
faci
al fi
xatio
n.
Ther
e w
as n
o si
gnifi
cant
diff
eren
ce b
etw
een
OR
IF o
f dis
plac
ed
frac
ture
s (>2
mm
) via
intra
oral
app
roac
h w
ith a
pplic
atio
n of
a si
ngle
m
onoc
ortic
al m
inip
late
ver
sus a
n ex
traor
al a
ppro
ach
with
app
licat
ion
of a
n in
ferio
r bor
der p
late
with
two
hole
s on
eith
er si
de o
f the
frac
-tu
re li
ne. F
unct
iona
l out
com
es in
clud
ing
pain
(vis
ual a
nalo
gue
scal
e sc
ore)
at t
he 1
-wee
k fo
llow
-up
and
inte
r-inc
isal
mou
th o
peni
ng a
t the
12
-wee
k fo
llow
-up
wer
e be
tter i
n ex
traor
al a
ppro
ach
grou
p. In
intra
oral
ap
proa
ch g
roup
, 25%
of p
atie
nts (
n =
5) h
ad a
pos
t-inj
ury/
pres
urgi
cal
neur
osen
sory
defi
cit,
whi
le in
ext
raor
al g
roup
, 50%
of p
atie
nts (
n =
10)
had
a po
st-in
jury
/pre
surg
ical
neu
rose
nsor
y de
ficit.
E. F
ran-
cios
i, et
al.
2014
, (8)
Arg
en-
tina
18 e
dent
ulou
s pat
ient
s, pr
e-se
nted
a to
tal o
f 35
man
dibu
lar
frac
ture
s
6 co
ndyl
ar fr
actu
res w
ere
treat
ed c
onse
rvat
ivel
y. 2
9 fra
ctur
es w
ere
treat
ed w
ith O
RIF.
Frac
ture
redu
ctio
n w
as c
onsi
dere
d sa
tisfa
ctor
y in
96.
5%, w
ith 2
2.2%
of
com
plic
atio
ns a
nd 1
1.1%
of r
eope
ratio
ns n
eede
d. 1
pat
ient
requ
ired
a re
oper
atio
n du
e to
uns
tabl
e fr
actu
re. C
ompl
icat
ions
: of f
acia
l ner
ve
inju
ries(
2) a
nd se
gmen
ts n
onun
ion
(1).
M. Leketas, E. Vedlugaitė, R. Kubilius SCIENTIFIC ARTICLES
Tabl
e 7.
Mai
n ch
arac
teris
tics a
nd fi
ndin
gs o
f rev
iew
ed st
udie
s (co
ntin
ued
from
pre
viou
s pag
e/co
ntin
ued
on n
ext p
age)
Stomatologija, Baltic Dental and Maxillofacial Journal, 2016, Vol. 18, No. 2 47
SCIENTIFIC ARTICLES M. Leketas, E. Vedlugaitė, R. Kubilius
Stud
yC
ount
rySa
mpl
eFr
actu
res t
reat
men
tM
ain
findi
ngs.
Com
plic
atio
ns o
ccur
renc
eA
. Rah
-pe
yma
, et
al. 2
014,
(2
5)
Iran
25 p
atie
nts (
28 fr
actu
re li
nes)
w
ith m
andi
bula
r fra
ctur
esTr
eatm
ent-t
wo
perp
endi
cula
r min
i-pla
tes v
ia e
xtra
oral
ap
proa
ch. F
ract
ure
line
fixat
ion
was
mad
e by
two
min
i-pla
tes p
erpe
ndic
ular
to e
ach
othe
r. 1-
wee
k IM
F an
d 3
wee
ks o
f sof
t die
t was
per
form
ed.
All
patie
nts w
ere
follo
wed
up
for a
t lea
st 1
yea
r reg
ardi
ng in
fect
ion
and
mal
occl
usio
n. A
mon
g th
e pa
tient
s who
und
erw
ent s
urge
ry, 1
mal
occl
u-si
on a
nd n
o ca
ses o
f inf
ectio
n w
ere
obse
rved
. No
faci
al n
erve
wea
knes
s ca
ses o
r dam
age
wer
e ob
serv
ed in
this
stud
y.S.
Bin
dra,
et
al.
2011
, (1
8)
Indi
a10
pat
ient
s with
dis
plac
ed
unila
tera
l/bila
tera
l con
dyla
r fr
actu
res
Trea
tmen
t – o
pen
redu
ctio
n an
d in
tern
al fi
xatio
n of
co
ndyl
ar fr
actu
res u
sing
retro
man
dibu
lar a
ppro
ach
Disc
repa
ncy
in o
cclu
sion
was
in 5
pat
ient
s (50
%) a
fter 2
4 h
and
1 w
eek
posto
pera
tivel
y, b
ut a
fter 3
mon
ths s
how
ed sa
tisfa
ctor
y ce
ntric
oc-
clus
ion.
Mou
th o
peni
ng a
nd la
tero
trusiv
e m
ovem
ents
incr
ease
d w
ith
time.
Prea
uric
ular
tend
erne
ss w
as in
4 p
atie
nts (
40%
) afte
r 1 w
eek,
in
2 pa
tient
s (20
%) a
t 6 w
eeks
and
non
e of
the
patie
nts h
ad p
reau
ricul
ar
tend
erne
ss a
fter 3
mon
ths.
Out
of 1
0, 2
pat
ient
s (20
%) h
ad c
licki
ng in
the
oper
ated
join
t one
wee
k po
stope
rativ
ely
whi
ch re
solv
ed g
radu
ally
. 4 p
a-tie
nts (
40%
) had
dev
iatio
n on
mou
th o
peni
ng to
war
ds th
e op
erat
ed jo
int
side
afte
r one
wee
k bu
t non
e ha
d an
y de
viat
ion
at 6
wee
ks o
r 3 m
onth
s po
stope
rativ
ely.
N. V
. V.
Red
dy, e
t al
. 201
2,
(26)
Indi
a17
5 co
ndyl
ar fr
actu
res
62.9
% o
f fra
ctur
es re
quire
d O
RIF
and
37.1
% w
ere
man
aged
with
clo
sed
redu
ctio
n.In
OR
IF g
roup
com
plic
atio
ns w
ere
sialo
ceol
e (2
cas
es),
ear d
ischa
rge
(1),
trans
cien
t fac
ial p
alsy
(19)
, occ
lusio
n di
sturb
anci
es (2
), sti
ch a
bsce
ss
(1),
trism
us (2
), pe
riodo
ntiti
s (4)
. In
IMF
grou
p oc
clus
ion
distu
rban
cies
(3
cas
es),
trism
us (4
), pe
riodo
ntiti
s (10
cas
es).
S.T.
Xie
, et
al.
2013
, (2
9)
Chi
na70
pat
ient
s with
con
dyla
r hea
d or
nec
k fr
actu
res
ORI
F w
as p
erfo
rmed
for a
ll th
e pa
tient
s. 38
wer
e tre
ated
with
mic
ropl
ates
and
32
with
min
ipla
tes.
The
max
imal
mou
th o
peni
ng w
as la
rger
in th
e m
icro
plat
e gr
oup
than
in
the
min
ipla
te g
roup
; sco
res f
or b
one
reso
rptio
n an
d co
ndyl
e m
orph
olog
y w
ere
bette
r in
the
mic
ropl
ate
grou
p. P
atie
nts f
rom
min
ipla
te fi
xatio
n ha
d a
signi
fican
tly h
ighe
r inc
iden
ce o
f TM
J clic
k.R
Pra
sad
, et
al.
2013
, (1
3)
Indi
a20
man
dibu
lar f
ract
ures
in 1
8 pa
tient
s Pa
tient
s wer
e tre
ated
by
ORI
F us
ing
3D p
late
s.A
signi
fican
t red
uctio
n in
ling
ual s
play
(72.
2%) a
nd o
cclu
sal s
tabi
lity
(72.
2%) w
as se
en. T
he o
vera
ll co
mpl
icat
ion
rate
was
(16.
6%):
post-
oper
ativ
e pa
resth
esia
of l
ip (2
), in
fect
ion
(3),
mas
ticat
ory
diffi
culty
(2).
No
evid
ence
of n
on-u
nion
, mal
unio
n w
as n
oted
.Z.
Li e
t al.
2013
, (23
)C
hina
13 p
atie
nts w
ith m
andi
bula
r co
ndyl
e di
sloc
atio
ns
Trea
tmen
t: (1
) rel
ief o
f the
disl
ocat
ion
by m
anip
ula-
tion
or o
pen
redu
ctio
n; (2
) red
uctio
n of
the
med
ial
cond
ylar
frag
men
t, fix
atio
n w
ith sc
rew
s, or
(3)re
mov
al
of th
e fra
gmen
t if l
ess t
han
50%
of t
he c
ondy
lar w
idth
.
Post
oper
ativ
ely,
all
patie
nts d
ispl
ayed
une
vent
ful h
ealin
g w
ithou
t com
-pl
icat
ions
such
as p
osto
pera
tive
haem
orrh
age
or in
fect
ion,
but
1 p
atie
nt
was
with
tran
sien
t fac
ial p
aral
ysis
with
reco
very
in 2
mon
ths.
Dur
ing
the
follo
w-u
p pe
riod,
no
patie
nts s
how
ed d
ysfu
nctio
n or
dev
elop
men
t of
ank
ylos
is, p
ain.
S.
Sch
iel ,
et
al.
2013
, (3
6)
Ger
-m
any
6 pa
tient
s with
dis
plac
ed c
on-
dyla
r bas
e an
d ne
ck fr
actu
res
(n =
9)
Ope
n su
rger
y, e
ndos
copi
cally
ass
isted
redu
ctio
n an
d fix
atio
n us
ing
a tra
nsor
al ro
ute.
All
patie
nts h
ad n
orm
al o
cclu
sion
, pa
in-f
ree
unre
stric
ted
TMJ f
unct
ion
at 3
, 6, 1
2, 1
8 m
onth
s pos
tope
rativ
ely.
The
re w
ere
no si
gns o
f inc
om-
plet
e re
mod
elin
g or
def
orm
atio
n.A
. Miji
ti,
et a
l. 20
14,
(11)
Chi
naA
tota
l of 1
350
patie
nts w
ith
max
illof
acia
l fra
ctur
es w
ere
revi
ewed
retro
spec
tivel
y
1860
frac
ture
s, 62
.4%
wer
e tre
ated
usin
g op
en
redu
ctio
n, 2
7.3%
usin
g cl
osed
redu
ctio
n, a
nd 1
0.3%
un
derw
ent o
bser
vatio
n on
ly
97 (7
.2%
) pat
ient
s had
loca
l com
plic
atio
n an
d 86
% o
f the
se w
ere f
ound
in
open
redu
ctio
n an
d ob
serv
atio
n gr
oups
. The
mos
t com
mon
com
plic
atio
n w
as tr
ansie
nt in
traor
al o
r ext
raor
al so
ft tis
sue i
nfec
tion
(64.
8% (6
3/97
) ca
ses)
, dist
urbe
d oc
clus
ion
and
anky
losis
25.
8% (2
5/97
) and
4.1
%(4
/97)
of
the a
ll co
mpl
icat
ions
, oste
omye
litis
(n=5
). A
. A. D
. A
dam
, et a
l. 20
12, (
41)
Chi
na31
0 pa
tient
s tre
ated
for z
ygo-
mat
ic b
one
and
zygo
mat
ic a
rch
frac
ture
s
Patie
nts t
reat
ed b
y O
RIF
with
min
ipla
te a
nd sc
rew
s co
nstit
uted
90.
6%, c
lose
d re
duct
ion-
9.4
%.
Mos
t pat
ient
s with
the
zygo
mat
ic b
one
and
zygo
mat
ic a
rch
had
no
com
plic
atio
n. C
linic
al e
xam
inat
ion
wer
e pe
rfor
med
at 4
, 6 a
nd 2
4 w
eeks
pos
tope
rativ
ely.
Tabl
e 7.
Mai
n ch
arac
teris
tics a
nd fi
ndin
gs o
f rev
iew
ed st
udie
s (co
ntin
ued
from
pre
viou
s pag
e/co
ntin
ued
on n
ext p
age)
48 Stomatologija, Baltic Dental and Maxillofacial Journal, 2016, Vol. 18, No. 2
M. Leketas, E. Vedlugaitė, R. Kubilius SCIENTIFIC ARTICLES
Stud
yC
ount
rySa
mpl
eFr
actu
res t
reat
men
tM
ain
findi
ngs.
Com
plic
atio
ns o
ccur
renc
eY.
Lei
ser,
et a
l. 20
13,
(22)
Isra
el37
pat
ient
s had
a fr
actu
re b
elow
th
e si
gmoi
d no
tch
(low
subc
on-
dyla
r)
10 p
atie
nts w
ere
treat
ed u
sing
the
ante
ropa
rotid
tra
nsm
asse
teric
(APT
M) a
ppro
ach,
27
wer
e tre
ated
co
nser
vativ
ely
by m
axilo
man
dibu
lar fi
xatio
n.
In th
e op
en re
duct
ion
grou
p, 2
pat
ient
s (20
%) h
ad li
mite
d m
outh
ope
n-in
g (r
esol
ved
follo
win
g ph
ysio
ther
apy)
; the
clo
sed
redu
ctio
n gr
oup
had
mou
th o
peni
ng li
mita
tion
(bel
ow 3
5 m
m) (
18.5
% o
f cas
es).
No
faci
al
nerv
e da
mag
e w
as n
oted
.T.
For
ou-
zanf
ar, e
t al
.201
3,
(34)
The
Net
her-
land
s
41 p
atie
nts w
ith b
ilate
ral c
ondy
-la
r fra
ctur
esCo
nser
vativ
e tre
atm
ent o
f bila
tera
l con
dyla
r fra
ctur
es
was
per
form
edO
f 41
pat
ient
s, no
pat
ient
had
cros
sbite
, 5 h
ad an
terio
r ope
n bi
te. N
o pa
tient
s with
mal
occl
usio
n ha
d an
y TM
J pai
n du
ring
6 m
onth
s.5 p
atie
nts
had
little
inte
nsity
or d
isabi
lity.
1 pa
tient
had
inte
nse p
ain
but l
ittle
disa
bilit
y,
1 pa
tient
had
mod
erat
ely
limiti
ng b
ut se
rious
ly d
isabl
ing
pain
. No
patie
nts
had
seve
rely
lim
iting
and
serio
usly
disa
blin
g pa
in.
J. H
. Zh
ou ,
et
al.2
013,
(3
0)
Chi
naA
tota
l of 7
8 pa
tient
s (10
0 co
n-dy
lar f
ract
ures
)A
prea
uric
ular
long
-cor
nifo
rm in
cisio
n fo
r ORI
F of
m
andi
bula
r con
dyla
r fra
ctur
es.
The
maj
ority
of p
atie
nts i
n al
l gro
ups h
ad g
ood
occl
usio
n (≥
88.5
%),
no
pain
(≥89
.5%
), an
d an
atom
ical
redu
ctio
n 10
day
s afte
r sur
gery
(≥81
.6%
). Th
ere
wer
e no
cas
es o
f joi
nt ri
gidi
ty, p
late
bre
akag
e, o
r scr
ew lo
osen
ing.
6
mon
ths a
fter s
urge
ry, t
here
wer
e 12
cas
es o
f mild
disp
lace
men
t and
5
case
s of p
oor a
nato
mic
al re
duct
ion.
At 6
mon
ths f
ollo
w-u
p, fr
actu
re
redu
ctio
n w
as id
eal i
n 83
% o
f cas
es.
R S
. Pat
il,
et a
l. 20
11,
(12)
Indi
a10
pat
ient
s with
low
sub-
cond
y-la
r fra
ctur
eTh
ese
patie
nts w
ere
treat
ed b
y op
en re
duct
ion
and
inte
rnal
fixa
tion
thro
ugh
intra
-ora
l app
roac
h.A
ll pa
tient
s fol
low
ed fo
r 6 w
eeks
, max
imum
mou
th o
peni
ng w
as m
ore
than
40
mm
in 7
pat
ient
s (ra
nge
from
40
to 5
0 m
m) a
nd le
ss th
an 4
0 m
m in
3 p
atie
nts.
Occ
lusi
on w
as sa
tisfa
ctor
y in
all
and
none
show
ed
devi
atio
n of
man
dibl
e on
mou
th o
peni
ng.
D. H
e, e
t al
. 200
9,
(20)
Chi
na22
9 pa
tient
s with
312
intra
ca-
psul
ar c
ondy
lar f
ract
ure
wer
e tre
ated
.
Trea
tmen
t pro
toco
l is o
pen
redu
ctio
n fo
r a fr
actu
re in
w
hich
the
supe
rola
tera
lly d
isloc
ated
ram
us st
ump
is ou
t of t
he g
leno
id fo
ssa
or a
ny ty
pe o
f fra
ctur
e w
ith
disp
lace
d or
disl
ocat
ed fr
agm
ents
that
may
cau
se T
MJ
dysf
unct
ion
late
r.
Of t
he jo
ints,
ORI
F w
as d
one f
or17
3; 9
5.6%
had
abso
lute
or n
early
anat
omic
re
duct
ion.
In al
l of t
hem
nor
mal
mou
th o
peni
ng an
d oc
clus
ion
wer
e res
tore
d.
No
or li
ttle d
evia
tion
was
foun
d du
ring
mou
th o
peni
ng. C
ompl
icat
ions
- pa
in in
the j
oint
(n=
1), c
repi
tatio
ns (n
= 2
), fa
cial
ner
ve p
aral
ysis
(n =
1).
2 pa
tient
s had
the p
late
rem
oved
bec
ause
of c
ompl
icat
ions
.G
. Ger
-bi
no, e
t al.
2009
, (19
)
Italy
50 p
atie
nts w
ith a
tota
l of 5
7 tre
ated
con
dyla
r fra
ctur
es w
ere
incl
uded
.
Ope
n re
duct
ion
and
inte
rnal
fixa
tion
Afte
r sur
gery
via
the r
etro
man
dibu
lar a
ppro
ach,
3 p
atie
nts h
ad sa
livar
y fis
tula
s. 1
patie
nt h
ad an
infe
ctio
n af
ter s
urge
ry v
ia th
e sub
man
dibu
lar a
p-pr
oach
. 6 p
atie
nts s
how
ed te
mpo
rary
faci
al n
erve
wea
knes
s (12
%),
but a
ll pa
tient
s rec
over
ed fa
cial
soft
tissu
e sym
met
ry w
ithin
8 w
eeks
. 2 p
atie
nts h
ad
perm
anen
t fac
ial n
erve
pal
sy (4
%).
Plat
e fra
ctur
es w
ere o
bser
ved
in 4
case
s. 3
patie
nts h
ad F
rey's
synd
rom
e, 3
had
mal
occl
usio
n, 4
7- h
abitu
al o
cclu
sion.
R S
chm
-el
zeis
en, e
t al
. 200
9,
(37)
Ger
-m
any
74 p
atie
nts w
ith c
ondy
lar n
eck
frac
ture
sTh
e no
nend
osco
pic
extra
oral
gro
up in
clud
ed 3
4 pa
-tie
nts a
nd th
e en
dosc
opic
ally
ass
isted
ope
n re
duct
ion
grou
p in
clud
ed 4
0 pa
tient
s.
The
patie
nts w
ith b
ilate
ral f
ract
ures
in b
oth
grou
ps sh
owed
dec
reas
ed
func
tion
at th
e fir
st fo
llow
-up
visit
com
pare
d w
ith u
nila
tera
l fra
ctur
es
patie
nts (
P =
.097
and
P =
.079
). Fa
cial
ner
ve d
amag
e w
as a
des
crib
ed
com
plic
atio
n, o
ccur
ring
in 1
5 pa
tient
s in
this
study
.R.
G
onzá
lez-
Gar
cía,
et
al. 2
009,
(9)
Spai
n17
pat
ient
s with
subc
ondy
lar
frac
ture
sTr
anso
ral e
ndos
copi
c-as
siste
d op
en re
duct
ion
and
fixat
ion
with
min
ipla
tes
No
dam
age
to th
e fa
cial
ner
ve w
as o
bser
ved.
No
visib
le sc
ars w
ere
pres
ent.
Tran
sitor
y hy
posth
esia
was
obs
erve
d in
3 c
ases
. 6 m
onth
s afte
r su
rger
y, th
e TM
J fun
ctio
n w
as n
ot im
paire
d. N
one
of th
e pa
tient
s com
-pl
aine
d of
pai
n. N
o co
ndyl
ar re
abso
rtion
was
pre
sent
.K
. Hw
ang,
et
al.
2010
, (1
0)
Kor
ea2,
094
patie
nts w
ith fa
cial
bon
e fr
actu
res
Clos
ed re
duct
ion
was
per
form
ed in
46.
3% o
f the
cas
es
whi
le 3
9.7%
of t
he c
ases
requ
ired
open
redu
ctio
nTh
e co
mpl
icat
ion
rate
was
6.4
% a
nd th
e m
ost c
omm
on c
ompl
icat
ion
was
hyp
oest
hesi
a (6
8.4%
) fol
low
ed b
y di
plop
ia (2
5.6%
). Th
e av
erag
e fo
llow
-up
perio
d fo
r hyp
oest
hesi
a w
as 1
.2 m
onth
s. Th
e av
erag
e fo
llow
-up
per
iod
for d
iplo
pia
was
2 m
onth
s.
Tabl
e 7.
Mai
n ch
arac
teris
tics a
nd fi
ndin
gs o
f rev
iew
ed st
udie
s (co
ntin
ued
from
pre
viou
s pag
e)
Stomatologija, Baltic Dental and Maxillofacial Journal, 2016, Vol. 18, No. 2 49
Our study about TMD showed that there was no case of maxillofacial fracture when TMD was noted, and there were some articles with the same results too. In condylar or subcondylar fractures cases where endoscopically assisted reduction and fixation was performed, normal pain-free unrestricted function of the TMJ was seen at 3, 6, 12, 18 months postop-eratively, TMJ function problems were not seen in any patient (17, 36). In subcondylar fractures which were treated by open reduction and internal fixation, all patients (n=10) had satisfactory occlusion and no deviation of mandible (12). In the article about trauma it was stated that in cases where early mobilization of TMJ and intensive physiotherapy after conservative or surgical treatment was applied, low postoperative complications rate (9%, n=5) was identified (24).
Although our study about TMD showed that there was no patient with TMJ problem after maxillo-facial fracture, there are studies which show different results. Temporomandibular joint complications such as pain, dysfunction, click or stiffness are observed for some time postoperatively (16, 20, 29, 33, 38), and it resolves gradually with time (18, 39). Long term follow-up period is important for TMJ treatment. For example, TMJ function was followed 6 months after surgery, and 18 months follow-up term for oc-clusion discrepancies and criterion of pain (17, 36). In long term follow-up period most of TMJ compli-cations decrease or disappear without any residual effects. In mandibular fractures where mostly closed reduction and intermaxillary fixation was performed TMJ dysfunction appeared in 30 of 164 cases (40). In mandibular cases where mostly open reduction and internal fixation was performed, postoperative complications rate, including TMJ, was 8.1% (7). In maxillofacial fractures which mostly were managed by open reduction and direct fixation TMJ stiffness appeared during first week after releasing intermax-illary fixation and it became normal after a week of physiotherapy (38). In condylar fracture cases which were treated mostly by open reduction (71.4%), complications such as mandibular movement devia-
tion (6 patients), TMJ clicking (2 cases), and pain (3 patients) was noted (33). In condylar fracture cases where open reduction and internal fixation was per-formed, in 2 of 10 cases TMJ clicking was noted one week postoperatively which disappeared gradually, 3 of 50 cases showed malocclusion, TMJ click was noted more in osteosynthesis miniplates group than in microplates group (P=0014), pain in TMJ area for 1 of 229, and crepitation for 2 of 229 (18-20, 29). In bilateral condylar fractures cases where conservative treatment was performed, no patients with malocclu-sion had any TMJ pain during 6 months, 5 patients had little intensity or disability of TMJ (34). There are different results of the studies about TMJ disorders after maxillofacial fracture.
The results of this research showed that results of mandible fractures are statistically significant, but more studies should be made in wider amplitude of years. The results of complications in the cases of zygomatic and maxillary fractures showed no statis-tical significance; therefore more studies should be done on this object.
CONCLUSIONS
The success of treatment depends on experience and practical skills of the surgeon and individual fracture conditions; therefore it is impossible to state which treatment technique is superior. Complications rate was higher in these cases where fractures were treated by closed reduction and indirect fixation. In the Department of Maxillofacial Surgery in Lithu-anian University of Health Sciences from 2012 to 2014 year complications of facial bones treatment rate was 6%. The most frequent complications were nerve injuries, bone regeneration complications and osteomyelitis. There was any of temporomandibular joint pathology as a complication.
CONFLICT OF INTEREST
None.
SCIENTIFIC ARTICLES M. Leketas, E. Vedlugaitė, R. Kubilius
REFERENCES
1. Nasser M, Pandis N, Fleming PS, Fedorowicz Z, Ellis E, Ali K. Interventions for the management of mandibular fractures. Cochrane Database Syst Rev 2013;(7):CD006087.
2. Chalya P, Mchembe M, Mabula J, Kanumba E, Gilyoma J. Etiological spectrum, injury characteristics and treatment outcome of maxillofacial injuries in a Tanzanian teaching hospital. J Trauma Manag Outcomes 2011;5:7.
3. Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: recommendations of the international RDC/TMD Consor-tium Network* and Orofacial Pain Special Interest Group†.
J Oral Facial Pain Headache 2014;28:6-27.4. Guruprasad Y, Hemavathy OR, Giraddi G, Shetty JN. An
assessment of etiological spectrum and injury characteristics among maxillofacial trauma patients of Government dental college and Research Institute, Bangalore. J Nat Sci Biol Med 2014;5:47-51.
5. Motamedi MH, Dadgar E, Ebrahimi A, Shirani G, Haghighat A, Jamalpour MR. Pattern of maxillofacial fractures: a 5-year analysis of 8,818 patients. J Trauma Acute Care Surg 2014;77:630-4.
6. Kubilius R, Keizeris T. Epidemiology of mandibular frac-tures treated at Kaunas University of Medicine Hospital,
50 Stomatologija, Baltic Dental and Maxillofacial Journal, 2016, Vol. 18, No. 2
M. Leketas, E. Vedlugaitė, R. Kubilius SCIENTIFIC ARTICLES
Received: 13 01 2015Accepted for publishing: 29 06 2016
Lithuania. Stomatologija. Baltic Dental and Maxillofacial J 2009;11:73-6.
7. Eskitascioglu T, Ozyazgan I, Coruh A, Gunay GK, Yontar Y, Altiparmak M. Fractures of the mandible: a 20-year retrospective analysis of 753 patients. Ulus Travma Acil Cerrahi Derg 2013;19:348-56.
8. Franciosi E, Mazzaro E, Larranaga J, Rios A, Picco P, Figari M. Treatment of edentulous mandibular fractures with rigid internal fixation: case series and literature review. Cranio-maxillofac Trauma Reconstr 2014;7:35-42.
9. Hwang K, Kim DH. Analysis of zygomatic fractures. J Craniofac Surg 2011;22:1416-21.
10. Hwang K, You SH. Analysis of facial bone fractures: An 11-year study of 2,094 patients. Indian J Plast Surg 2010;43:42-8.
11. Mijiti A, Ling W, Tuerdi M, Maimaiti A, Tuerxun J, Tao YZ, et al. Epidemiological analysis of maxillofacial frac-tures treated at a university hospital, Xinjiang, China: A 5-year retrospective study. J Craniomaxillofac Surg 2014;42:227-22.
12. Patil RS, Gudi SS. Management of subcondylar fracture through intraoral approach with rigid internal fixation. J Maxillofac Oral Surg 2011;10:209-15.
13. Prasad R, Thangavelu K, John R. The role of 3D plating system in mandibular fractures: A prospective study. J Pharm Bioallied Sci 2013; 5(suppl.1):S10-3.
14. Schenkel JS, Obwegeser J, Zemann W, Rostetter C, Tandon R, Metzler P. Outcome of comminuted mandibular fracture repair using an intraoral approach for osteosynthesis. J Craniofac Surg 2015;25:2033-7.
15. Seemann R, Schicho K, Wutzl A, Koinig G, Poeschl WP, Krennmair G, et al. Complication rates in the operative treat-ment of mandibular angle fractures: a 10-year retrospective. J Oral Maxillofac Surg 2010;68:647-50.
16. Van dB, Heymans MW, Duvekot F, Forouzanfar T. Treat-ment and complications of mandibular fractures: A 10-year analysis. J Craniomaxillofac Surg 2012;40:e108-11.
17. Gonzalez-Garcia R, Sanroman JF, Goizueta-Adame C, Rodriguez-Campo FJ, Cho-Lee G. Transoral endoscopic-assisted management of subcondylar fractures in 17 patients: An alternative to open reduction with rigid internal fixation and closed reduction with maxillomandibular fixation. Int J Oral Maxillofac Surg 2009;38:19-25.
18. Bindra S, Choudhary K, Sharma P, Sheorain A, Sharma CB. Management of mandibular sub condylar and condylar fractures using retromandibular approach and assessment of associated surgical complications. J Maxillofac Oral Surg 2010;9:355-62.
19. Gerbino G, Boffano P, Tosco P, Berrone S. Long-term clini-cal and radiological outcomes for the surgical treatment of mandibular condylar fractures. J Oral Maxillofac Surg 2009;67:1009-14.
20. He D, Yang C, Chen M, Jiang B, Wang B. Intracapsu-lar condylar fracture of the mandible: our classification and open treatment experience. J Oral Maxillofac Surg 2009;67:1672-9.
21. Kamath RAD, Bharani S, Hammannavar R, Ingle SP, Shah AG. Maxillofacial Trauma in Central Karnataka, India: an outcome of 95 cases in a regional trauma care centre. Cra-niomaxillofac Trauma Reconstr 2012;5:197-204.
22. Leiser Y, Peled M, Braun R, Abu-El Naaj I. Treatment of low subcondylar fractures - a 5-year retrospective study. Int J Oral Maxillofac Surg 2013;42:716-20.
23. Li Z, Ongodia D, Wu ZX, Li ZB. Clinical characteristics and treatment of superolateral dislocation of the mandibular condyle. Int J Oral Maxillofac Surg 2013;42:1575-81.
24. Munante-Cardenas JL, Asprino L, De Moraes M, Alber-garia-Barbosa J, Moreira RWF. Mandibular fractures in a group of Brazilian subjects under 18 years of age: A
epidemiological analysis. Int J Pediatr Otorhinolaryngol 2010;74:1276-80.
25. Rahpeyma A, Khajehahmadi S, Barkhori Mehni S. Treat-ment of mandibular fractures by two perpendicular mini-plates. Iran J Otorhinolaryngol 2013;26:31-36.
26. Reddy NV, Reddy PB, Rajan R, Ganti S, Jhawar DK, Potturi A, Pradeep. Analysis of patterns and treatment strategies for mandibular condyle fractures: review of 175 condyle fractures with review of literature. J Maxillofac Oral Surg 2013;12:315-20.
27. Salentijn EG, van den Bergh B, Forouzanfar T. A ten-year analysis of midfacial fractures. J Craniomaxillofac Surg 2013;41:630-6.
28. Singh V, Khatana S, Bhagol A. Superior border versus inferior border fixation in displaced mandibular angle fractures: prospective randomized comparative study. Int J Oral Maxillofac Surg 2014;43:834-40.
29. Xie ST, Singhal D, Chen CT, Chen YR. Functional and radiologic outcome of open reduction and internal fixation of condylar head and neck fractures using miniplate or microplate system. Ann Plast Surg 2013;71(suppl 1):S61-6.
30. Zhou J, Ren C. A preauricular long-corniform approach for open reduction and internal fixation of mandibular condylar fractures. J Craniomaxillofac Surg 2013;41:359-66.
31. Ulusoy S, Kayiran O, Ozbaba N, Celebi S, Caglar E, Oghan F. Changing strategies in the treatment of maxillofacial fractures at thrace region: open vs closed reduction. Oral Health Dent Manag 2014;13:8-13.
32. Singh V, Bhagol A, Goel M, Kumar I, Verma A. Outcomes of open versus closed treatment of mandibular subcondylar fractures: a prospective randomized study. J Oral Maxillofac Surg 2010;68:1304-9.
33. Shi J, Chen Z, Xu B. Causes and treatment of mandibu-lar and condylar fractures in children and adolescents: a review of 104 cases. JAMA Otolaryngol Head Neck Surg 2014;140:203-7.
34. Forouzanfar T, Lobbezoo F, Overgaauw M, de Groot A, Kommers S, van Selms M, van den Bergh B. Long-term results and complications after treatment of bilateral frac-tures of the mandibular condyle. Br J Oral Maxillofac Surg 2013;51:634-8.
35. Prade V, Seguin P, Boutet C, Alix T. Outcome of endo-scopically assisted surgical treatment of mandibular condyle fractures: a retrospective study of 22 patients. Rev Stomatol Chir Maxillofac Chir Orale 2014;115:333-42.
36. Schiel S, Mayer P, Probst F, Otto S, Cornelius C. Transoral open reduction and fixation of mandibular condylar base and neck fractures in children and young teenagers - a beneficial treatment option? J Oral Maxillofac Surg 2013;71:1220-30.
37. Schmelzeisen R, Cienfuegos-Monroy R, Schon R, Chen C, Cunningham Jr L, Goldhahn S. Patient benefit from endoscopically assisted fixation of condylar neck frac-tures- a randomized controlled trial. J Oral Maxillofac Surg 2009;67:147-58.
38. Singh V, Malkunje L, Mohammad S, Singh N, Dhasmana S, Das SK. The maxillofacial injuries: A study. Natl J Maxil-lofac Surg 2012;3:166-71.
39. Kanno T, Sukegawa S, Nariai Y, Tatsumi H, Ishibashi H, Furu-ki Y, Sekine J. Surgical treatment of comminuted mandibular fractures using a low-profile locking mandibular reconstruc-tion plate system. Ann Maxillofac Surg 2014;4:144-9.
40. Leuin SC, Frydendall E, Gao D, Chan KH. Temporo-mandibular joint dysfunction after mandibular fracture in children: a 10-year review. Arch Otolaryngol Head Neck Surg 2011;137:10-4.
41. Adam AAD, Zhi L, Bing LZ, Zhong Xing WU. Evaluation of treatment of zygomatic bone and zygomatic arch frac-tures: a retrospective study of 10 years. J Maxillofac Oral Surg 2011; 11:171-6.
Top Related