Immediate live-saving emergency treatment of patients with heavily communited and partially defective mandibles by airway intubation, control of haemorhage and primary treatment of wounds necessarily must be followed by a staged concept of treatment for the functional and aesthetic rehabilitation of hard and soft tissue in order to enable the patient to survive not only biologically but also socially. Out of 384 patients with surgically treated mandibular fractures, 120 had multiple fractures, 24 heavily comminuted fractures and 6 sustained vast defects. All multiple and communited fractures could be treated successfully by an intraoral approach using function-orientated miniplate-osteosynthesis and in 30 cases functionally stable plates. In patients having sustained vast avulsions of soft and hard tissue, immediate emergency-revascularisation was well to the fore. In cases of tissue destruction, primarily the position of the jaw stumps was secured by plates and reconstruction was done in the early secondary stage using composed microvascularly transferred scapular flaps.
Retrospective analysis of 712 patients with 1166 mandibular fractures and follow up-study of 374 patients with 593 fractures was performed for discrimination of differences in wound- and bone-healing as well as late results between operative and conservative fracture treatment. 46.1% (328) of all patients have been treated conservatively, 53.9% (384) have been treated by operation. The follow up was performed on 255 patients with operative fracture treatment and 119 patients with conservative treatment. In 3.0% of the operatively treated patients bacterial infections occurred, in comparison to 8.7% of conservatively treated patients. From the viewpoint of functional aspects, such as occlusion, articulation and mandibular movement as well as radiological signs in the fractured region patients after operative treatment have shown partly significantly better results during the follow up compared to the group of conservatively treated patients. Neurological testings of inferior alveolar nerve and mental nerve have shown significantly better results in the group of conservatively treated patients. Since the functional results are much better after operative treatment, osteosynthesis with miniplates should be performed if there are no contraindications. The more precise reconstruction and stabilization of the fragments shortens time of hospitalization and leads to sooner functionality of the mandible.
The stable osteosynthesis of mandibular fractures with the modified lag screw (Krenkel) has proven superior to conventional lag screws in theoretical models and clinical use. Compared to osteosynthesis with plate systems, the lag screw technique is more difficult to learn for the unexperienced, but the reduction of fragments under compression with a lag screw and the stabilisation of lower jaw rotation with an additional short miniplate in our experience has proven successful in clinical use.
About 50 years after the end of World War II 84 former soldiers of the German army were examined for aftereffects of their war injuries. Among the data recorded for analysis were the age at which the injury was incurred, the examination intervals, the region affected by the injury and the cause of the injury, but also the different levels of aftereffects of injuries. A total of 53 applicants had suffered mandibular injuries. Considering the wide scattering range, it can be concluded that values of about 20 percent represent a mean degree of incapacitation, primarily due to a combination of loss of teeth and parts of the alveolar process and the effects on the prosthetic support. Casuistic examples illustrate special histories or developments including sarcomagenesis in the region originally affected by the injury.
43 patients with gunshot wounds of the mandible were treated in Tübingen and Basel between 1968 and 1995. Among them were 31 patients ( = 72.09%) with bone loss and defect fractures. Over that time period the treatment principles of gunshot wounds have not changed. They are based on an early soft tissue closure and an approach from the inside to the outside. Besides that modern techniques in maxillofacial reconstructive surgery, which include the application of biocompatible plates and screws and the introduction of microvascular reconstructive techniques, have enlarged the therapeutical options. Every patient needs an individual approach to his special medical condition, which is illustrated in three exemplary cases. The combination of the above mentioned modern reconstructive techniques prevents long and multiple hospital stays and invalidity. Furthermore it is the basis for social reintegration as well as functional and esthetic rehabilitation.
The Ultrasound technique as an image producing procedure for fractures of the mandibular collum is outlined with physical theory and clinical examples. Advantages and disadvantages are compared and it is stated that a part of all patients with fractures might have a benefit from this method. Mentally handicapped patients, pregnant women and all sorts of fidgety patients will profit by the ultrasound investigation as the only way to ascertain the bone-fracture. There is necessity to relate the sonogram to a conventional X-ray picture whenever it is possible, for the procedure is suited to prove the fracture, not to exclude it.
Because treatment of fractures of the atrophic mandible still today presents significant difficulties and treatment modalities remain controversial, 87 of these consecutive fractures which were treated by an uniform method as compression osteosynthesis were evaluated. A new classification of the degree of atrophy which considers the special interest of fracture treatment is introduced. It is based on a metrical measurement of the height of the mandible in the fracture area. Mandibles of 16 to 20 mm height are classified as class I atrophy, those of 11 to 15 mm as class II atrophy, and those with a height of 10 mm or less as extremely atrophic mandibles or class III atrophy. This simple and reliable classification could also be used in future investigations on the results of different treatment modalities in atrophic mandibles. In our series of 87 fractures of the atrophic mandible which were treated by compression osteosynthesis 97% resulted in a solid osseous union without the need of a second surgical intervention. Three major complications occurred: 1 osteomyelitis and 2 non-unions (the latter in one patient with a double fracture of a class III atrophy mandible). To the best of our knowledge this series is the largest of fractures of truly atrophic mandibles treated by one uniform method. Compared to other treatment modalities compression osteosynthesis produced acceptable results and is recommended as the treatment of choice in fractures of the atrophic mandible.
In a prospective study posttraumatic and postoperative sensitivity disturbances after mandible fractures in the region of osseous course of the inferioralveolar nerve were assessed. The study contains 28 patients with 31 mandible fractures. For assessment somato sensoric evoked potentials and computer assisted pain and thermal sensitivity testing was used. A rate of 32% posttraumatic and 52% nerve disturbances resulting from osteosynthesis was found. In 81% the sensitivity disturbances lasted only 6 months post-operatively. In 19%, mainly cases of fracture dislocation of 5 mm minimum, anesthesia and hypesthesia lasted for more than half a year.
During a period of 8 years (1986-1994) we treated 183 patients with mandibular fractures. Within this period we changed our treatment protocol from the rigid internal fixation (AO/ASIF method) to monocortical noncompression miniplates. The complications of 127 AO/ASIF cases versus 41 miniplate cases were studied. Complications mostly consisted in dehiscences. Comparing the two methods we found more complications (19.5%) when the AO plate is applicated via an intraoral approach. After extraoral AO treatment and after monocortical miniplates there was no significant difference concerning our complications (8.1% versus 7.3%).
This paper presents the results of the treatment of fractures of the mandibular angle using miniplate osteosynthesis. From 1984 to 1993 347 patients with 358 fractures were operated in the department of Maxillofacial Surgery at the University of Cologne. In all cases total bone healing could be observed while complications were rare.
We report about our experience in five patients who suffered from a mandibular micrognathia after ancylosis of the temporomandibular joint. At first the ancylosis was removed using a costochondral graft. About one year later, the mandible was cut by an osteotomy behind the last visible toothbud and a distractor was inserted. The mandible was to a slide overcorrection. This has to be taken into account to compensate a certain relapse. At first we used an unidirectional device, for one and a half years we have used a bidirectional device (Normed from Tuttlingen/Germany) which enables us to correct mandibular hypoplasias more adequately. Up to now our experience shows, that gradual callus-distraction leads to stable normalization of mandibular hypoplasias. Functional problems concerning chewing and speech are solved, the dramatical improvement of the profile of the face may avoid psycho-social problems for these patients.
A sample of 91 patients who had suffered from condylar fractures in the years 1970-1977 could be followed up. The mean follow up period was 19.8 years. As a prognostic relevant parameter the patient's age at the time of the accident as well as the type of the fracture where taken into account. Clinically young (8-11 years at the time of the accident) patient's with no or low grade dislocation showed the best results. Almost 36% of the patients with high grade dislocation or luxation presented measurable pathological changes during function. The condylar movement was assessed by using 3D-optoelectronic measurement. Despite severe radiographic alterations and hindered condylar translation in cases with high grade dislocation or luxation, mouth opening was not restricted in the majority of the patients. It seems that the lack of condylar translation is compensated by extensive rotation.
The present study was designed to investigate biomechanical and clinical changes in the mandibular complex by means of finite element analysis. An analytical model developed from human native mandibles was used for this model, CT image data were transferred to a computer, and an edge extraction program generated the cross-section of bone by specifying a range of CT values for each slice. Pixel data from the CT scan were converted into a vector of points (x, y, z) which can specify the boundaries of bone. Lateral surfaces are defined by stacking up the slices and making use of the vectorized data. The constructed model was used as input data for the finite element analysis. The models were solved for stresses and forces. The highest principal stresses occurred at the bite point, anterior aspects of the coronoid processes, symphyseal region, and right and left sides of the mandibular corpus. For further investigation muscular structures have to be integrated to establish a model, which can be analysed under multivariate aspects.
Late results and complications following rigid internal fixation of mandibular fractures-a 10 year survey. From 1984 to 1993 541 fractures of the mandible in 332 patients have been treated by rigid internal fixation with the mandibular compression system (MCS). In 0.8% we saw serious complications like pseudarthrosis or osteomyelitis. In a retrospective study 105 patients with 171 fractures of the mandible could be examined 4.1 years after osteosynthesis. In case of preoperative normesthesia of the inferior alveolar nerve in 74.1% of the fractures nomesthesia was still present, 18.1% of the fractures showed hypesthesia and 4.2% showed complete anesthesia. In case of already preoperatively existent hypesthesia in 81.8% of the fractures normesthesia and in 8.2% hyp- or paresthesia were seen. There were no anesthesias seen in this group. 3.6% of the fractures showed mild occlusal disharmonies.
In a retrospective study on 302 patients, miniplate osteosynthesis (n = 236) and rigid internal fixation (n = 66) in patients with fractures of the mandible were investigated. The total complication rate following miniplate osteosynthesis was 6.5% compared to 12.7% following rigid internal fixation. Additional intermaxillary immobilisation did not avoid postoperative complications. In patients with multiple or comminuted fractures of the mandible, rigid internal fixation demonstrated a lower complication rate compared to miniplate osteosynthesis.
The study including fifty children younger than 10-years-old with dislocated unilateral collum fractures concerns the chronological development of morphological alterations in the orthopantomogramm. Regardless of fracture type, the radiographs indicate, that a very good restitution can be attained with an exclusive functional therapy using an activator in all analyzed patients. A realignment can not be found.
A geometrically closed quadrangular plate secured with bone screws creates stability in three dimensions. The smallest structural component of a 3-D-plate is an open cube or a square stone. Our clinical results and biomechanical investigations have shown a good stability of the 3-D-plates in the osteosynthesis of mandibular fractures without major complications. The thin 1.0 mm connecting arms of the plate allow easy adaptation to the bone without distortion. The free areas between the arms permit good blood supply to the bone.
