Treatment modalities for mandibular angle fractures

Purpose: Management of mandibular angle fractures is often challenging and results in the highest complication rate among fractures of the mandible. Optimal treatment for angle fractures remains controversial. Historically, treatment of mandible fractures included intraoperative maxillomandibular fixation (MMF) along with rigid internal fixation. More recently, noncompression plates miniplates, which produce only relative stability, have gained popularity. The absolute necessity of intraoperative MMF as an adjunct to internal fixation has also become controversial. The current trends in the management of simple, noncomminuted mandibular angle fractures are examined. Materials and Methods: A survey was submitted to North American and European AO ASIF (Arbeits-gemeinschaft für Osteosynthesefragen Association for the Study of Internal Fixation) faculty in July 2001. Statistical analysis of results included both Fisher's exact and chi-square tests. Results were considered significant if P <.05. Results: One hundred ten of 127 potential responses were received (87%). Among 104 surgeons who treat mandible fractures, 86 (83%) treat more than 10 mandibular fractures per year. Preferred techniques for simple, noncomminuted mandibular angle fractures in this group were: single miniplate on the superior border (Champy technique) with or without arch bars (44 surgeons, 51%); tension band plate on the superior border and nonlocking, bicortical screw plate on the inferior border (11 surgeons, 13%); dual miniplates (9 surgeons, 10%); a locking screw plate on the inferior border only (6 surgeons, 7%), and 3-dimensional plates (5 surgeons, 6%). Eleven surgeons (13%) gave multiple answers. Although only 13% of surgeons surveyed primarily use the combination of tension band and nonlocking, bicortical screw plates, many surgeons (73%) continue to use this technique in certain circumstances. Within this group, 32 (51%) place screws in a neutral position, while 31 (49%) place screws in an eccentric position, resulting in compression. For simple noncomminuted angle fractures, the number of surgeons performing internal fixation without MMF were: 14 often (16%); 20 occasionally (23%); 17 seldom (20%); and 35 never (41%). Surgeons treating more than 10 versus those who treat less than 10 fractures per year, International versus North American faculty, and Oral and Maxillofacial surgeons (OMS) versus non-OMS surgeons were compared. Surgeons who treat more than 10 fractures per year favor the Champy technique over the tension band and bicortical plate combination (44 [51%] vs 11 [13%]), while those surgeons who treat less than 10 per year favor the tension band and bicortical plate combination over the Champy technique (9 [50%] vs 3 [17%]; P <. 01, Fisher exact test). International faculty are less likely to use intraoperative MMF than North American faculty (29 [81%] vs 31 [43%]; P <. 01, Fisher exact test). OMS surgeons are less likely to use the tension band and bicortical plate combination than non-OMS surgeons (22 [56%] vs 42 [90%]; P <. 017, Fisher exact test). Conclusion: This survey suggests an evolution in the management of mandibular angle fractures. A single miniplate plate on the superior border of the mandible has become the preferred method of treatment among AO faculty. When using large, inferiorly based plates more surgeons are now favoring neutral rather than eccentric screw placement. Intraoperative MMF is not considered mandatory by some surgeons in certain circumstances.