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ORIGINAL ARTICLE - COMPARATIVE STUDY
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 10-15

2 mm conventional miniplates with three-dimensional strut plate in mandibular fractures


1 Department of Oral and Maxillofacial Surgery, ITS Dental College, Greater Noida, Lucknow, Uttar Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Career Post Graduate Institute of Dental Sciences and Hospital, Lucknow, Uttar Pradesh, India
3 Department of Dentistry, TS Misra Medical College and Hospital, Lucknow, Uttar Pradesh, India

Date of Submission25-Mar-2019
Date of Acceptance07-Apr-2020
Date of Web Publication8-Jun-2020

Correspondence Address:
Dr. Manish Dubey
Department of Dentistry, TS Misra Medical College and Hospital, Lucknow, Uttar Pradesh
India
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DOI: 10.4103/ams.ams_73_19

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  Abstract 


Aim: The aim of this study was to compare 2 mm conventional miniplates with three-dimensional (3D) strut plates in the treatment of mandibular fractures treated in the Department of Oral and Maxillofacial Surgery of a college in India, during 2012–2015. Materials and Methods: All 20 patients with mandible fracture requiring open reduction and internal fixation of the fracture were reported and reviewed in the Department of Oral and Maxillofacial Surgery of the same dental college in India, during 2012–2015. We classified the data according to the gender, age, etiology, fracture site, and method of treatment of the fractures. Fixation done in 10 patients with 2 mm conventional miniplates kept in Group I, while 10 patients with 3D strut miniplate system considered in Group II. Results: Assessment of patient was done under the following parameters with follow-up at regular intervals at 2nd day postoperatively and at 1st, 3rd, and 6th weeks postoperatively: pain, swelling, infection, interincisal mouth opening in millimeters, paresthesia/anesthesia, mobility between fracture fragments, overall occlusion, need for any supplemental fixation, fate of implant, and complications. Conclusions: 3D titanium miniplates showed similar results when compared to standard titanium miniplates with advantages such as reduction in operative time, ease of placement, and cost-effective over the conventional plate system.

Keywords: Biocompatibility, maxillofacial trauma, osteosynthesis, rigid and semi-rigid fixation, three-dimensional titanium miniplates


How to cite this article:
Kaushik S, Ali I, Dubey M, Bajpai N. 2 mm conventional miniplates with three-dimensional strut plate in mandibular fractures. Ann Maxillofac Surg 2020;10:10-5

How to cite this URL:
Kaushik S, Ali I, Dubey M, Bajpai N. 2 mm conventional miniplates with three-dimensional strut plate in mandibular fractures. Ann Maxillofac Surg [serial online] 2020 [cited 2020 Dec 2];10:10-5. Available from: https://www.amsjournal.com/text.asp?2020/10/1/10/286177




  Introduction Top


Over the years, the methods to treat mandibular fractures have undergone many refinements. Newer methods have been tried and older ones have had improvements. Two approaches to mandibular fracture fixation have evolved: one is rigid stabilization, proposed by Spiessl,[1] and the other one is semi-rigid fixation, proposed by Champy et al.[2],[3] Both the techniques have disadvantages, as the adaptation of the plate to the bone is difficult and time-consuming with rigid fixation, while fracture stability cannot be guaranteed with semi-rigid stabilization.[4] A three-dimensional (3D) plate may overcome these shortcomings.

Farmand and Dupoirieux[5] developed the concept of 3D miniplates whose shape is based on the principle of the quadrangle as a geometrically stable configuration for support. The basic form is quadrangular with 2 × 2 hole square plate and 3 × 2 or 4 × 2 hole rectangular plate. The plates are adapted to the bone according to the Champy's principles.

3D miniplate gives 3D stability to the fractured segments during healing. Locking system does not allow screw loosening and alteration in bone alignment or occlusal discrepancies on screw tightening. 3D locking plates have been designed with the hypothesis that this will overcome the disadvantages of both the systems, and also, advantages of both the systems will be combined for the management of mandibular fractures.

3D miniplate is formed by joining two miniplates with interconnecting vertical crossbars. The fundamental idea of the 3D bone plate is based on the principle of a quadrangular as a geometrically stable configuration for support. Increased stability is achieved by the geometric shape of the quadrangular plate rather than by its thickness or lengths.[6],[7],[8] In the quest of an ideal implant material, maximum research has been directed toward titanium in the current century. Titanium is considered to be the most biocompatible alloplastic material. The biocompatibility stability and clinical experiences of titanium 3D miniplates have been well described recently by Faramnd and Wittenberg et al.[6],[7] The introduction of 3D strut plate/screw system has certain theoretical advantages over conventional plates and screws such as greater stability across fracture site, smaller incision, and lesser hardware requirement.


  Materials and Methods Top


Source of data

All 20 patients with mandible fracture requiring open reduction and internal fixation of the fracture were reported and reviewed in the Department of Oral and Maxillofacial Surgeryof a dental college in India, during 2012–2015.

Inclusion criteria

Noncomminuted mandibular fractures requiring open reduction and internal fixation were included in the study.

A maximum number of surgeries were performed via an intraoral approach. Cases having preexisting scars were performed via extraoral/transbuccal approach.

Exclusion criteria

Patients having systemic diseases where general anesthesia is contraindicated with a history of uncontrolled diabetes mellitus, prolonged steroid therapy, compromised immunity, and associated pathology at or near fracture site and with a history of previous mandibular fracture or osteotomies were excluded from the study.

The patients were randomly categorized into two groups irrespective of age, sex, caste, and socioeconomic status.

  • Group 1: having 10 patients where fracture fixation was done with 2 mm conventional or standard miniplate system [Figure 1]
  • Group 2: having 10 patients where fracture fixation was done 2 mm 3D strut plate systems [Figure 2].
Figure 1: Fixation with 2 mm conventional or standard miniplate system

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Figure 2: Fixation with 2 mm three-dimensional strut plate system

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Thorough clinical, radiological, and laboratory evaluation of the patient was done to identify any criteria which would exclude the patients from the study; in addition, fitness of the patients to undergo the procedure was done.

Postoperative care

Postoperatively, intravenous (IV) antibiotics were used injection ceftriaxone 1 g 12 hourly combined with metrogyl 100 ml 8 hourly. The antibiotics were continued for 5 days postoperatively. If any subsequent infection occurred, the antibiotics were changed according to the culture and sensitivity reports. The patients were put on dexamethasone 8 mg 8 hourly IV postoperatively, and the dosage tapered down in subsequent 3–4 days to decrease edema and inflammation in the surgical site. However, arch bars, if placed, were retained for 2–3 weeks without intermaxillary fixation. A radiograph was taken postoperatively to check the adequacy of reduction and fixation. After discharge, the patients were recalled on the 1st week, 3rd week, 3rd month, and 6th month. On each appointment apart from routine examination and wound care, the patients' maximal mouth opening, occurrences of any complication were assessed.

Postoperative assessment

The assessment of patients was done under the following parameters with follow-up at regular intervals of 2nd day postoperatively and at 1st, 3rd, and 6th weeks postoperatively: pain, swelling, infection, interincisal mouth opening in millimeters, paresthesia/anesthesia, mobility between fracture fragments, overall occlusion, need for any supplemental fixation, the fate of implant, and complications.

The statistical analysis was done using the Statistical Package for the Social Sciences version 15.0 statistical analysis software Arun Statistics, Lucknow (UP) India. The values were represented in number (%) and mean ± standard deviation (SD). The following statistical formulas were used:

1. Mean: To obtain the mean, the individual observations were first added together and then divided by the number of observations. The operation of adding together or summation is denoted by the sign S.

The individual observation is denoted by the sign X, number of observation denoted by n, and the mean by ̄X.



2. SD: It is denoted by the Greek letter s. If a sample is more than 30, then



When sampling in <30, then



3. Chi-square test:



Where O = observed frequency,

E = Expected frequency

4. Student's t-test: To test the significance of two means, the Student's t-test was used





Where ̄X1, ̄X2 are means of Group 1 and Group 2

N1 and N2 are the number of observations in Group 1 and Group 2 respectively.

SD1 and SD2 are standard deviations in Group 1 and Group 2, respectively.

5. The Wilcoxon signed-rank statistic W+ is computed by ordering the absolute values |Z 1|, |Z n|, the rank of each ordered |Z i| is given a rank of R i. Denote Where i is an indicator function. The Wilcoxon signed-rank statistic W+ is defined as







6. Level of significance: “P” is the level of significance

P > 0.05: Not significant

P < 0.05: Significant

P < 0.01: Highly significant

P < 0.001: Very highly significant.


  Results Top


The patients underwent thorough clinical examination and radiological examination followed by management, followed by the assessment of patients with follow-up at regular intervals of 2nd day postoperatively and at 1st, 3rd, and 6th weeks postoperatively. The results of the present study were as followed.

No statistically gender difference was found.

The range of operative procedure in Group I was 1.5 and 2 h, while that in Group II, it was 1 and 1.5 h. The mean duration of the operative procedure in Group II (1.20 ± 0.26 h) was significantly lower than that of Group I (1.43 ± 0.34 h).

All the procedures performed on patients of Group I were found difficult in comparison of Group II by the surgeons. The difference in ease of procedure was found to be statistically significant (P < 0.001).

The minimum time for placement of miniplates in Group I was 15 min and the maximum time was 19 min, while in Group II, the minimum time for placement of miniplates was 5 min and the maximum time was 10 min. Time for placement of miniplates in Group II (7.20 ± 1.81 min) was found to be significantly lower than that of Group I (16.70 ± 1.25 min) [Table 1].
Table 1: Between-group comparison of time of placement of graft (min)

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In both, the groups' reduction in mouth opening ranged between 1 mm and 3 mm. Despite being the same range of reduction in mouth opening, reduction in mouth opening was significantly lower in Group II (1.40 ± 0.70) as compared to Group I (1.75 ± 0.72) and the difference in reduction in mouth opening of both the groups was found to be statistically significant (P = 0.024).

At follow-up at 2 days postoperatively, moderate swelling was found on all the patients of Group I (100.0%), While 30% of the patients in group II was having moderate swelling and rest 70% with mild swelling. The difference in swelling in both the groups was found to be statistically significant (P < 0.001). At follow-up at 1 week, moderate swelling was found in a higher proportion of patients of Group I (n = 4; 40.0%) as compared to Group II (n = 2; 20.0%), but this difference was not found to be statistically significant (P = 0.329) [Table 2].
Table 2: Between-group comparison of postoperative pain at different time intervals

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After 1 week of postoperative follow–up, no mobility, infection, paresthesia, or failure was seen in any of the group. In our study, no radiographic evidence of plate fracture was noted in patients in Group 1 or Group 2 in follow-up period postoperatively. Occlusion was arranged, and no change in the union between different follow-up periods was found.


  Discussion Top


Experiments conducted by Champy et al. to validate mandibular osteosynthesis according to the Michelet's principle affirmed that the mandibular cortex is strong enough to induce strains resulting from screws. Champy advised the use of two miniplates in the anterior region, one at the inferior border and second 5 mm above the lower plate. Miniplates were placed within 10 mm of the superior border, but in the anterior part of the mandible in front of the premolar, torsional movements were greater and higher when they were near the mandibular symphysis.[9],[10],[11]

Internal fixation using miniplates and screws in maxillofacial surgery is regarded as the “gold standard.” The main functional advantages of miniplates are improved jaw function (in terms of mouth opening and bite force), patient comfort, improved speech, and oral hygiene and enhanced social interaction.[12],[13],[14]

The 3D titanium plating system for mandibular fracture treatment is relatively new and was introduced by Farmand in 1992. The 3D miniplates consist of one 4 hole miniplates or two 4 hole miniplates joined by three or four interconnecting cross struts. 3D plates are positioned parallel to the fracture line. The connecting arms of the plate should be positioned rectangular to the fracture line. The main cause for mandibular fracture in our study was road traffic accidents, which also in accordance with the literature Gabrielli andMarcantons (2003), Bonmann et al. (2009), and Berg and Heymans (2012).[15],[16],[17] This is probably due to the growing number of automobiles on the road and rash high-speed driving with inadequate enforcement of traffic safety rules.

In our study, age of presentation ranged from 15 to 45 in Group 1 with a mean age of 27 years and 25–60 years in Group 2 with a mean age of 36 years, which is similar to that reported in the literature by Gabrielli and Marcantons (2003) and Bonmann et al. (2009).[15],[16] This could be explained due to more active lifestyle of this age group with increasing age more involvement in physical activities, fast and rash driving, interpersonal violence, alcohol abuse, and contact sports, while the people beyond 40 years are less affected by the incidence of fracture as they lead more calm, peaceful, and disciplined life.

A male predominance was noted in our study, the percentage of males with mandibular fracture was 95% and that of female was 5% which is similar to that reported in the literature by Gabrielli and Marcantons (2003) and Bonmann et al. (2009).[15],[16] This is probably due to higher levels of physical activity among men and more socially active life led by this group of individuals.

3D plate requires less surgical exposure and less time for placement, which might explain why operative procedures performed in Group 2 was easier as compared to Group 1 in our study. This is well supported by Sehgal et al. (2014) and Gandi and Kattimani (2012).[18],[19]

Less operating time was found in Group 2 when compared to Group 1. The range of operative time procedure in Group 1 was 1.5–2 h, while that in Group 2, it was 1–1.5 h. This is due to less time required in the placement of plates in Group 2 as compared to Group 1. In Group 2, the time of placement of plate ranges from 5 to 10 min, and in Group 1, it ranges from 15 to 19 min which also in accordance with the literature Guimond et al. (2005) and Babu et al. (2007).[20.21] In Group 1, conventional miniplates required a longer time because these are linear plates and two plates are required for fixation at the parasymphysis or symphysis region. On the other hand, in Group 2, 3D plate is a geometric plate which consists of two horizontal bars interconnected with two vertical bars. Hence, single 3D plate stabilized the fracture at both the superior and inferior borders at a time; hence, time is saved in plate fixation.

Moderate swelling was observed on 2nd postoperative day in Group 1, whereas mild swelling was observed in Group 2. This could be due to smaller incision, less soft tissue dissection, and less time required for adaptation of 3D plate in case of Group 2. Swelling became reduced and disappeared subsequently on postoperative follow-ups, which also in accordance with literature by Khalifa et al. (2012) and Gandi and Kattimani (2012).[18],[19]

No patients in Group 1 or Group 2 developed postoperative pain in our study. Reduction in mouth opening after the procedure was lower in Group 2 with a mean of 1.40 as compared to Group 1 with a mean of 1.75. This is due to less time consumption and less surgical exposure required during the operative procedure in Group 2 as compared to Group 1.

No patients in Group 1 or Group 2 developed infection, paresthesia, mobility between fragments, or any other complications similar to the literature by Sehgal S et al 2014 Ebenezer and Ramalingam (2011), and Gandi and Kattimani (2012).[18],[19],[21],[22] This concurs with the findings of Guimond et al. (2005) where 5.4% infection rate was observed,[20] Gabrielli andMarcantons (2003) reported 10%–15% infection rate mostly in the angle region,[15] and Berg and Heymans 2012 reported infected osteosynthesis material in five patients.[22]

In our study, occlusion was arranged in both the groups which also in accordance with Guimond et al. (2005) and Sehgal et al.[19],[20] This concurs with the findings of Khalifa et al. (2012) where two patients in each group had slight occlusal discrepancy which was successfully corrected by simple selective coronoplasty in two patients and guiding elastics in two cases.[23]

No radiographic place fracture evidence was noted in both the groups in a postoperative follow-up. This is in accordance with the results reported in the literature by Berg and Heymans (2012).[17]

Cases of oblique fracture or the fracture running through the mental foramina required more time in the placement of 3D plate. This might be due to difficulty in achieving principles of 3D plate fixation (horizontal bar perpendicular and vertical bar parallel to fracture line) which results in limitation in using 3D plate in such cases. In such cases, the plate was placed either inferior or superior to the foramina, and care has been taken while placing the plate superior to the foramina so that the screws are placed between the roots of the teeth. Another limitation of 3D plate was excessive implant material resulting from extra vertical bars incorporated for countering the torque forces which is in agreement with Babu et al. and Wittenberg et al.'s studies.[7],[21] In our study, no such cases were reported where 3D plate was placed near the area of the mental foramina.

The quadrangle geometry of the 3D plate assures a 3D stability of fracture sites as it offers good resistance against torque forces. A 2 mm 3D titanium miniplate provides sufficient inter-fragmentary stability with relatively low complication rates and decreased risk of plate fracture and subsequent infection when compared with a single 2 mm standard miniplate.


  Conclusion Top


Based on the finding of our study, the following conclusions were derived:

  1. Patients in the 27–37 years of age were the predominant age group presenting with a mandibular fracture
  2. The most common cause of mandible fracture was found to be road traffic accidents with male predominance
  3. Because of the closed quadrangular geometric shape, a single 3D plate stabilized the fracture both at the superior and inferior borders at a time; hence, there was a reduction in operative time
  4. With the 3D titanium miniplate osteosynthesis technique, less surgical exposure of the underlying fracture site is needed, consequently less traction of the surrounding soft tissue leads to a more comfortable postoperative period
  5. The implant was able to counteract forces along the fracture site, thus precluding hardware failure
  6. Use of 3D miniplates is cost-effective in comparison to conventional miniplates as less number of plates and screws were needed.


We concluded that the 3D titanium miniplates showed similar results when compared to standard titanium miniplates with advantages such as reduction in operative time, ease of placement, and cost-effective over the conventional plate system.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Spiessl B. Rigid internal fixation of fractures of the lower jaw. Reconstr Surg Traumatol 1972;13:124-40.  Back to cited text no. 1
    
2.
Champy M, Loddé JP, Schmitt R, Jaeger JH, Muster D. Mandibular osteosynthesis by miniature screwed plates via a buccal approach. J Maxillofac Surg 1978;6:14-21.  Back to cited text no. 2
    
3.
Michelet FX, Deymes J, Dessus B. Osteosynthesis with miniaturized screwed plates in maxillo-facial surgery. J Maxillofac Surg 1973;1:79-84.  Back to cited text no. 3
    
4.
Kroon FH, Mathisson M, Cordey JR, Rahn BA. The use of miniplates in mandibular fractures. An in vitro study. J Craniomaxillofac Surg 1991;19:199-204.  Back to cited text no. 4
    
5.
Farmand M, Dupoirieux L. The value of 3-dimensional plates in maxillofacial surgery. Rev Stomatol Chir Maxillofac 1992;93:353-7.  Back to cited text no. 5
    
6.
Formand M. The 3D plating in maxillofacial surgery. J Oral Maxillofac Surg 1993:51:166-7.  Back to cited text no. 6
    
7.
Wittenberg JM, Mukherjee DP, Smith BR, Knuse RN. Biomechanical evaluation of new fixation device for mandibular fracture for mandibular fractures. Int J Oral Maxillofac Surg 1997;26:68-73.  Back to cited text no. 7
    
8.
Wittenberg JM, Smith BR, Trigg DD. Treatment of mandibular angle fractures with 3D titanium mini plates. J Oral Maxillofac Surg 1994;52:106.  Back to cited text no. 8
    
9.
Champy M, Lodde JP, Schmitt R, Jaeger JH, Muster D. Mandibular osteogenisis by miniature screw plate via a buccal approach. J Max b-Fac Surg 1963;6:14-21.  Back to cited text no. 9
    
10.
Michelet FX, Deymes J, Dersus B. Osteosynthesis with miniature screweds plate in maxillofac surgery. J Oral Maxillofac Surg 1973;1:79-84.  Back to cited text no. 10
    
11.
Choi BH, Huh Y. An in vitro evaluation of miniplate fixation techniques for fractures of the atrophic edentulous mandible. Int J Oral Maxillofac Surg 2005;34:174-7.  Back to cited text no. 11
    
12.
Snell JA, Dott WA. Internal fixation of certain fractures of the mandible by bone plating. Plast Reconstr Surg 1969;43:281-6.  Back to cited text no. 12
    
13.
Hayterb JP, Cawood JI. The functional care for miniplate in maxillofac surgery. Int J Oral Maxillafac Surg 1993;22:91-6.  Back to cited text no. 13
    
14.
Saluja H, Kini V, Mahindra U. A comparative evaluation of parasymphysis fracture: A pilot study. Int J Oral Maxillofac Surg 2012;41:906-11.  Back to cited text no. 14
    
15.
Gabrielli MA, Marcantons E. Fixation of mandibular fracture with 2.0 mm miniplates: A reviw of 191 cases. J Oral Maxillofac Surg 2003;1:430-7.  Back to cited text no. 15
    
16.
Bonmann KH, Wild S, Gellrich NC, Kokemullar H, Stunmere C. Five-year retrospective study of mandibular fractures Germany: Incidence etiology, treatment and complication. J Oral Maxillofac Surg 2009:67:1251-5.  Back to cited text no. 16
    
17.
Berg BV, Heymans MW. Treatment and complication of mandibular fractures: A 10 years analysis. J Cranio Maxillofac Surg 2012;20:E108-1.  Back to cited text no. 17
    
18.
Gandhi L, Kattimani VS. Three dimensional bone plating system in the management of mandibular fractures—a clinical study. Annals of esthetic dentistry 2012;4:42-52.  Back to cited text no. 18
    
19.
Sehgal S, Ramanajum L, Sehgal K. Three dimentional verus standard tritanium miniplate fixation in the management of madiubular mini plate fixation in the mangemnent of mandibular fracture – A randomized clinical study. J Cranio Maxillofac Surg 2014;30:1-8.  Back to cited text no. 19
    
20.
Guimond C, James V, Jhonson J. Fixation of mandibular angle fractures with 2 mm 3D curved angle strut plate. J Oral Maxillofac Surg 2005:63:209-14.  Back to cited text no. 20
    
21.
Parmar S, Menat S, Raghani M, Kapadia T. Three dimensional miniplate rigid fixation in fracture mandible. J Maxillofac Oral Surg 2007;6:14.  Back to cited text no. 21
    
22.
Ebenezer V, Ramalingam B. Three dimentional maniplate fixation in mandibular angle fracture. Indian J Multidiscip Dent 2011;1:118-264.  Back to cited text no. 22
    
23.
Khalifa ME, El-Hawary HE, Hussein MM. Titanium three dimensional miniplate versus conventional titanium miniplate in fixation of anterior mandibular fractures. Life Sci J 2012;9:1006-1009.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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