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TRAUMATIC MANDIBULAR FRACTURES: PENDULUM SWINGING TOWARDS CLOSED REDUCTION??

Authors:  Rahul Gupta*, Rahul Gupta, Sukanya Suryanarayan*, Abhishek Sharma**, Vishala K.Pandya***, Swati Sathaye****

*Senior Resident, **Junior Resident, ***Associate Professor, ****Professor

Institution:   Dept. of E.N.T. & Head-Neck Surgery, Medical College & S.S.G. Hospital, Vadodara-390001, Gujarat, India

Corresponding Author:  Dr. Rahul Gupta

Dept. of E.N.T. & Head-Neck Surgery,
Medical College & S.S.G.Hospital,
Vadodara-390001
Gujarat, India

Abstract:

Aims:  The aim is to study the use of simple and effective methods for the treatment of mandibular fractures.

Materials and methods:   Thirty-three patients with traumatic mandibular fractures have been studied. These patients opted for closed reduction & intermaxillary fixation and decided against open reduction with plating. Criteria for evaluation of the results were mouth opening, occlusion and deformity correction. Other related studies were also reviewed.

Results:   The resultant mouth opening was good in 97% of the cases. Almost all cases had good occlusion and facial deformity was seen only in one case. None of our patients had poor outcome in any category. 12% of the patients had a slightly compromised outcome.

Conclusion:  Closed reduction and IMF gives good results in the form of occlusion, mouth opening and cosmesis. This technique is patient compliant and cost effective.

 
Introduction:

The face of man is formed of soft expressive tissues, draped upon an underlying framework of bony structures. It is endowed with an inherent ability to convey emotions through the interplay of flexible facial structure.

Maxillofacial injuries are common both in war and peace. With the exception of the nose, mandibular fractures occur twice as frequently as fractures of other facial bones. The mandible is the largest and strongest bone of the face, but because of its rigid structure and commanding position it is often the subject of trauma resulting in fracture. The importance of the mandible is not only cosmetic but also functional in biting, chewing and speaking.

The plethora of techniques available for the management of mandibular fractures tells us that there is still a controversy regarding their definitive treatment. The technique employed in the individual case will reflect the preference of the surgeon, wishes of the patient and the availability of specialized surgical facilities. The aim of this study is to find out a simple but effective method for the treatment of mandibular fractures.

Methods:

This is a prospective study of 33 patients with traumatic mandibular fractures who opted for treatment by closed reduction with IMF.  The study was conducted in the time period of January 2008 to December 2009.

A preliminary assessment was done after taking care of airway and hemodynamics to look for head, abdominal, chest and extremity injuries which took priority over maxillofacial fractures.

A careful clinical examination was performed externally and intraorally in sequential manner to include all regions of the face.  Infection was specifically looked for in old and compound injuries and if present was immediately tackled with antibiotics.

The clinical findings were then correlated with diagnostic radiographic imaging.  Conventional radiological studies were performed according to the region of the mandible which was likely fractured.  Most commonly used views for suspected mandibular fractures included complete series with P/A, oblique and lateral views.  Orthropan tomogram was done in most of the patients.  CT scans (coronal and sagittal) with 3-D reconstruction were done in a few patients.

All the patients were explained two basic modalities of treatment:  Open reduction with plating and closed reduction with intermaxillary fixation.  Most of our patients opted for closed reduction and IMF as they considered it nonsurgical.  Two patients who opted for open reduction and internal fixation have been excluded from this study.

The first step was the placement of the Arch bar or Ivy’s loop.  This was the only pre-procedure preparation for IMF in cases of undisplaced fractures.  In case of a displaced fracture, the Arch bar was split. Elastic traction was then applied for 24 to 72 hours to achieve proper reduction of the fracture fragments.  This requires daily evaluation and changing of elastics for 2 to 3 days.  Once proper and adequate reduction was achieved, fixation with IMF was done. This IMF was usually kept for a period of 4-6 weeks for good healing of the fracture.

In the case of subcondylar/condylar fractures, elastics were first applied to get proper alignment of the mandible on Arch bar or Ivy loops.  It was kept for 5 days with daily changing of elastics. Then IMF was done.  The IMF was kept for 2 -3 weeks. Elastics were again applied post-IMF for 7 days as a part of physiotherapy.

The patients were given definitive advice regarding oral hygiene.  Dietary counseling was given to all patients and they were advised to have liquid diet with the help of a straw.  Patients were explained to drink milk with ghee, mashed bananas and fruit juices.  Oral antibiotics were given for 5 days. The patients were followed regularly for any new complaint, loosening and protrusion of wire, oral hygiene and signs of local infection, etc., till removal of the IMF.

The patients were assessed for nutritional status, dental hygiene, average loss of working days and weight on the day IMF was removed.  Functional and cosmetic results were evaluated at the end of one month after removal of the IMF according to the following criteria:

1. According to Mouth opening:  Good ( MO > 3 Fingerbreadth); Fair ( MO between 2-3 Fingerbreadth) and Poor (MO < 2 Fingerbreadth)

2. According to Occlusion:  Good (Neutrocclusion), Fair (malocclusion not functionally significant) and Poor significant Malocclusion)

3. According to deformity correction:  Good (No cosmetic deformity), Fair (Minimal cosmetic deformity that is noticeable objectively which includes scarring, minimal depression of face, widened face, chin deviation on mouth opening), and Poor (gross deviation of chin, retruded and displaced midface and mandible)

Results

All of the patients healed well with closed reduction and IMF.  None of the patients had nonunion.
The result according to mouth opening was good in 34 (97%).  There was slight restriction of mouth opening in 1 patient which can be put in the Fair group.

94% of the cases had good occlusion.   Two (6%) patients had malocclusion after completion of treatment.  Although they were able to chew without pain but on examination malocclusion was evident.
Facial deformity was seen only in one case in the form of widening of the jaw.

None of the patients had a poor outcome in any category.  Dental caries developed in one patient.

The patients in our study lost an average of 3.9kg weight.  Maximum weight loss was 11 kgs in one patient.  No patient suffered from any medical complication due to weight loss.

Case I:  Fracture of the Right Body of the Mandible

Preop Angle of Mandible Fracture Pre Op Angle of Mandible Fracture
Pre Treatment Occlusion
   
Post Op Angle of Mandible Fracture Post Op Angle of Mandible Fracture
Post Treatment Occlusion

There is loss of teeth and anterior open bite seen in the preoperative photograph,. IMF was done with use of Arch bar. Post treatment, there is Neutrocclusion. There was a weight loss of 6kg in this patient.
   

Case II:  Bilateral Angle of Mandible Fracture:

Case II Bilateral Angle of Mandible Fracture

Post Op Occlusion of Mandible Fracture - Case II

Post Op View in Neutral
Occlusion

 


Discussion

There is always a search for a treatment which gives faster and perfect results without any side effects.  Unfortunately such treatment does not exist especially for traumatic mandibular fractures.

The basic principle of any fracture treatment is reduction, fixation, immobilization, prevention of infection and rehabilitation. IMF provides both fixation and immobilization in cases of favorable fractures but prolong immobilization is required.  On the other hand, plating provides only fixation and immobilization is done by IMF, but it is required for a lesser period of time.  Various authors like Terris DJ, et al,1 (1994) and Sorel B2 (1998) have reviewed the indications for closed and open reduction.  Closed reduction was the most frequently used method with minimal complication rate.

In favorable fractures, the results in terms of occlusion, mouth opening and cosmesis are equal and comparable by both of the methods.  The technique employed in the individual case will reflect the preference of the surgeon and the availability of specialized surgical facilities. If the treatment provider is comfortable in both the techniques, choice can be given to patients.
Closed reduction and intermaxillary fixation was the only method for centuries.  Most mandibular fractures were treated either by approximate fixation using internal stainless steel wires, external fixation using rigid metal pins or custom-made silver cap splints (cast metal covering of all the teeth in the arch).  The major disadvantage of this method is that the patient has to survive on a liquid diet for 4 to 6 weeks and oral cleaning cannot be properly done due to wiring and closed mouth.

One important factor worth noting is weight loss due to dietary restrictions.  In our study, patients lost an average of 3.9kg weight.  Maximum weight loss was 11kg.  This is especially of concern when the patients are already underweight or malnourished or has other associated debilitating injury.  It has to be mentioned here that open reduction and plating are best for those people who are professional voice users and require full mouth opening as soon as possible.  Our set of patients did not have any patients in this category.

If a patient wearing IMF requires airway assistance due to some other cause, it becomes difficult and time consuming.  There have been occasional incidences of prick injuries to the operator while performing IMF.  If the patient is suffering from sero communicable disease, repeated manipulation of wires is potentially hazardous.

Internal fixation with plates, pins or screws eliminates the need for prolonged intermaxillary fixation but has its own disadvantages of anesthetic/surgical risks apart from the cost of fixtures.  Initial results of internal fixation with plating were encouraging and enthusiastic.

Omar Abubaker, Gregg. T.Lyman3 in 1988 found from their 3 year study that even though the actual cost of ORIF throughout the study period was higher than that of closed reduction, when the cost of treating postoperative complications, the use of the ICU and the number of postoperative follow up visits was considered the use of ORIF was found to be more cost effective than closed reduction and MMF.  In a similar study, Brian.L.Schmidt, Gerard Kearns, Newton Gordon, Leonard Kaban4 in the year 2000 comparing the cost effectiveness of mandibular fracture treatment found that even though the initial cost of ORIF is more than double that of closed reduction, the overall cost of treating patients by ORIF was much lesser than that for closed reduction.

Later clinicians started critical comparison between open and closed reduction of mandibular fractures.
A more recent randomized study on financial analysis of closed versus open reduction method described by Schmidt BL. ,et al,4 (2000) and Shetty V ,et al, 5 (2008) with respect to cost of primary and secondary surgery and visits to the clinic for immediate and delayed complications showed that closed reduction of mandibular fracture cost significantly less than open reduction.

For both of the methods, the average hospital stay and follow up visits remains almost the same.  Thus cost of transport for the treatment and loss of working days would be equal.  The difference is in the fixtures and procedure cost of the treatment. In a government hospital like ours, surgical charges are minimal. All the instruments and fixtures are available in government supply.  Even then when given a choice for deciding their treatment, patients usually decided for closed reduction and IMF. Hence, it is expected that when they have to pay extra for surgery, anesthesia and fixtures, they would be even less willing to select an open reduction.  It is sometimes based on their mindset which is influenced by socio-familial belief. They consider closed reduction and IMF a non-surgical treatment as there is no incision and stitches. Patients were even prepared for restricted and liquid diet as part of therapy. Many patients observe self restriction to various foods for early and uncomplicated recovery from most illness. Dietary restriction and mouth closure for a few weeks was not considered to be a limitation by the patient.

Conclusion

Closed reduction and IMF is a commonly accepted method for treatment of traumatic mandibular fracture when the patient is not a professional voice user.  Closed reduction and IMF gives good results in the form of mouth opening, occlusion and cosmesis for a majority of patients having mandibular fracture.  Some weight loss is bound to occur but it is of concern if the patient is already malnourished or underweight.

 
References:

1.  Terris DJ, Lalakea ML, Tuffo KM, Shinn JB. Mandible fracture repair: specific indications for newer techniques. Otolaryngol Head Neck Surg. 1994 Dec;111(6):751-7.  View Abstract

2.  Sorel B.  Open versus closed reduction of mandible fractures.  Oral and Maxillofacial Surgery Clinics of North America. 1998; 10:553.

3.  Abubaker AO, Lynam GT. Changes in charges and costs associated with hospitalization of patients with mandibular fractures between 1991 and 1993. J Oral Maxillofac Surg. 1998 Feb;56(2):161-7; discussion 167-8.   View Abstract

4.  Schmidt BL, Kearns G, Gordon N, Kaban LB. A financial analysis of maxillomandibular fixation versus rigid internal fixation for treatment of mandibular fractures. J Oral Maxillofac Surg. 2000 Nov;58(11):1206-10; discussion 1210-1.  View Abstract

5.  Shetty V, Atchison K, Leathers R, Black E, Zigler C, Belin TR. Do the benefits of rigid internal fixation of mandible fractures justify the added costs? Results from a randomized controlled trial. J Oral Maxillofac Surg. Nov 2008; 66(11):2203-12.   View Abstract

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World Articles in Ear, Nose and Throat  www.waent.org                 June 16, 2010              Vol 3-1

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