J Oral Maxillofac Surg

61:430-436, 2003

Fixation of Mandibular Fractures With

2.0-mm Miniplates: Review of 191 Cases
Marisa Aparecida Cabrini Gabrielli, DDS, PhD,*
Ma
rio Francisco Real Gabrielli, DDS, PhD,
Elcio Marcantonio, DDS, PhD,
and Eduardo Hochuli-Vieira, DDS, PhD
Purpose:

Our goal was to study the use of 2.0-mm miniplates for the fixation of mandibular fractures.
Patients and Methods: Records of 191 patients who experienced a total of 280 mandibular fractures
that were treated with 2.0-mm miniplates were reviewed. One hundred twelve of those patients,
presenting 160 fractures, who attended a late follow-up were also clinically evaluated. Miniplates were
used in the same positions described by AO/ASIF. No intermaxillary fixation was used. All patients
included had a minimum follow-up of 6 months. Demographic data, procedures, postoperative results,
and complications were analyzed.
Results: Mandibular fractures occurred mainly in males (mean age, 30.3 years). Mean follow-up was
21.92 months. The main etiology was motor vehicle accident. The most common fracture was the angle
fracture (28.21%). Twenty-two fractures developed infection, for an overall incidence of 7.85%. When
only angle fractures are considered, that incidence is increased to 18.98%. Although only 1 patient
(0.89%) described inferior alveolar nerve paresthesia, objective testing revealed sensitivity alterations in
31.52% of the patients who had fractures in regions related to the inferior alveolar nerve. Temporary mild
deficit of the marginal mandibular branch was observed in 2.56% of the extraoral approaches performed
and 2.48% presented with hypertrophic scars. Incidence of occlusal alterations was 4.0%. Facial asymmetry was observed in 2.67% of the patients, whereas malunion incidence was 1.78%. Fibrous union,
mostly partial, occurred in 2.38% of the fractures, but only 1 of those presented with mobility (0.59%).
Condylar resorption developed in 6.25% of the fixated condylar fractures. Mean mouth opening was
42.08 mm.
Conclusion: The overall incidence of complications, including infections, was similar to those described for more rigid methods of fixation.
2003 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 61:430-436, 2003
fragments, allowing immediate return to function.1 It
is not always easy to define what is adequate fixation
for a given mandibular fracture. This is dependent on
the characteristics of the fracture, patient, and kind of
postoperative function desired for the particular case.
It is usually accepted that noncomminuted symphyseal and parasymphyseal fractures, as well as condylar
fractures, can be treated with two 2.0-mm miniplates1
and that selected angle linear fractures can be treated
with an upper border 2.0-mm miniplate and still allow
immediate function.2 In the present study, we reviewed 191 patients treated for different kinds of
mandibular fractures with a 2.0-mm miniplate system.

Rigid internal fixation of mandibular fractures eliminates the need for intermaxillary fixation and facilitates stable anatomic reduction while reducing the
risk of postoperative displacement of the fractured
Received from the Division of Oral and Maxillofacial Surgery, University Dentistry School at Araraquara, Araraquara, Sao Paulo,
Brazil.
*Professor.
Chairman.
Professor.
Professor.
Address correspondence and reprint requests to Dr Gabrielli:
Departament of Oral and Maxillofacial Surgery, Rua Humaita, 1680,
P Box 331, CEP 14801-903, Araraquara, SP, Brazil; e-mail: macg@
foar.unesp.br

Patients and Methods:

PATIENTS

2003 American Association of Oral and Maxillofacial Surgeons

One hundred ninety-one facial trauma patients with

mandible fractures who were treated in the hospitals

0278-2391/03/6104-0005$30.00/0
doi:10.1053/joms.2003.50083

430

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GABRIELLI ET AL

Santa Casa de Miserico

rdia, Beneficiencia Portuguesa,
and Hospital Sao Paulo, in Araraquara, Sao Paulo,
Brazil, by the same oral and maxillofacial surgeons
were included in this study. All patients were operated on between January 1990 and November 1998
and had mandible fractures treated with a 2.0-mm
miniplate system (Engimplan, Rio Claro, Sao Paulo,
Brazil). The thickness of the plates in that system was
0.90 mm; the width was 4.63 mm. The head diameter
of the screws was 2.98 mm; the core diameter, 1.92
mm; and the thread; 1.98 mm. The minimum postoperative follow-up required for inclusion in this retrospective study was 6 months.
FRACTURE FIXATION

Fracture treatment was undertaken under general

anesthesia. Intermaxillary fixation was used in all dentate patients before fixation of the fractures. In the
edentulous patients, the reduction was anatomic,
without use of surgical guides or splints, except when
dentures were available or could be repaired. No
postoperative intermaxillary fixation was used in either dentate or edentulous patients. In some cases,
postoperative elastics were used, 1 on each side, to
guide the occlusion.
Fractures of the symphysis and of the anterior body
region were treated through an intraoral approach.
All other regions received extraoral approaches as
described by Ellis and Zide.3 When teeth in the line of
fracture had to be extracted, this was done after
fixation of the fracture. With the exception of condyle and ramus fractures, all others were stabilized,
most of the time, with a 6-hole plate at the inferior
border and bicortical screws combined with an upper
border 4-hole plate and bicortical screws wherever
possible. Otherwise, monocortical screws were used.
In cases where an arch bar could function as a tension
band, only the lower border plate was used. Fractures
of the condyle were stabilized with one or two 4-hole
plates and bicortical screws.
After the procedure was completed, intermaxillary
fixation was removed, leaving the arch bars in place,
and the occlusion was verified. Intraoral incisions
were closed with resorbable sutures, whereas extraoral wounds were closed in layers. All patients
received postoperative antibiotics for 7 days and were
instructed to maintain a soft diet for 30 days. Clorhexidine mouth rinses (0.12%) were used postoperatively
for 7 days.

technique. The fractures were classified as nondisplaced, displaced (5 mm), severely displaced (5
mm), and comminuted. Teeth in the line of fracture
were evaluated, as was the dental status of the patient. In the postoperative radiographs, reductions
were classified as adequate or inadequate. The presence of bone resorption, signs of infection, bonehealing quality, removal of fixation material, and
tooth extractions were also assessed.
CLINICAL EVALUATION

All patients were asked to return for a clinical

examination to collect data for this study. The clinical
evaluation assessed in 112 patients the presence of
paresthesia, facial palsy, malocclusion, facial symmetry, surgical scars, infection, postoperative endodontic treatment or loss of teeth, exposed fixation material or need for plate removal, presence of bone or
soft tissue lesions, and pseudoarthrosis or malunion.
Paresthesia was evaluated by pinprick and light touch
with a cotton mesh, also comparing with the nonoperated side when the fracture was unilateral. Facial
nerve dysfunction was assessed by clinical observation of movement and comparison of symmetry.

Results
Mandibular fractures occurred in 151 male patients
(79.06%) and 40 females (20.94%). Age varied from 6
to 87 years old, with a mean of 30.3 years (Fig 1).
Mean follow-up was 21.92 months, ranging from 6
months to 8 years.
The causes were motor vehicle accidents (51.82%),
aggravated assaults (24.61%), falls from the ground
(12.57%), sports (3.66%), accidents with animals
(2.62%), falls from heights above 2 m (2.10%), working accidents (1.05 %), gunshot wounds (1.05%), and
truck tire explosion (1.05%).
Ninety-eight patients (51.31%) had 2 or more mandible fractures. Thirty-four fractures (12.14%) in 20

RADIOGRAPHIC EVALUATION

Panoramic, Townes view, and posteroanterior

mandibular radiographs were obtained preoperatively, as well as after 7, 30, and 45 days and 3, 6, and
12 months postoperatively in 191 patients. These
films were obtained to document outcomes of this

FIGURE 1. Age distribution of the treated patients.

432

MINIPLATE FIXATION OF MANDIBULAR FRACTURES

Table 1. DISTRIBUTION OF FRACTURES ACCORDING

TO SITE

Site of Fracture

No. of Fractures

Angle
Parasymphyseal
Body
Condyle
Symphysis
Ramus
Total

79
59
55
48
33
6
280

28.21
21.07
19.64
17.14
11.79
2.15
100.0

patients (10.47%) occurred in edentulous mandibles,

129 fractures (46.07%) in 87 patients (45.55%) occurred in partially edentulous mandibles, and 117
fractures (41.79%) in 84 patients (43.98%) occurred in
mandibles with complete dentitions. The distribution
of the fractures according to site is shown in Table 1.
Thirty-eight patients (19.89%) had also middle third
fractures as shown in Table 2.
Radiographic evaluation revealed 66 fractures
(23.57%) were severely displaced (5 mm), 129
(46.07%) were displaced (5 mm), and 26 (9.29%)
were comminuted. Of the 79 angle fractures
(28.21%), 56 (70.88%) were associated with third
molars in the line of fracture. Twenty-one third molars
were removed. In 14 cases, those teeth were removed
during the fracture treatment. Eight were totally
erupted and 6 were partially impacted. In 7 cases, 5
erupted and 2 partially impacted teeth, all involved
with varying degrees of infection, were removed postoperatively. In one case the tooth involved was
treated endodontically.
All patients (n 191) were considered in the retrospective evaluation of the incidence of infection.
Twenty-one patients (10.99%) presented a total of 22
(7.85%) infected fractures. Most infections occurred
in the angle region. Figure 2 shows the number of
infected fractures according to region. The earliest
infection was seen 7 days after treatment and the
latest after 1 year, with a mean of 64.33 days. When
the 79 angle fractures are considered, 15 (18.98%)
were associated with infections, although in only 6
cases (7.59%), the bone was actually infected (Fig 3).
Removal of the fixation material was required in 13
patients (14 fractures), due to infection. Plates and

FIGURE 2. Infected fracture distribution according to site (n 22).

screws were removed from 10 fracture sites in 9

patients and only screws from 4 patients. Two patients needed a secondary surgical procedure and
fixation with 2.4-mm reconstruction plates, 2 received
reconstruction plates with bone grafts, 1 was treated
with a longer 2.0-mm plate, and another received
wire ostheosynthesis and intermaxillary fixation for 6
weeks. In addition to the patients with infection, 2
had internal fixation material removed. One had fractures of the plates bilaterally, which were used to
treat body fractures on an edentulous mandible. This
was treated with longer 2.0-mm plates, and fortunately the fractures healed although the material was
inadequate. One patient had the fixation removed to
install osseointegrated implants. Thus, 15 patients
(7.85%), with 17 fractures (6.07%), had internal fixation hardware removed. Among those, the most common region for removal was the angle region with 9
fractures (52.98%) of all infected cases. Four body
fractures, of which 2 were infected, had the fixation
removed, as well as 4 symphysis fractures (23.54%).
Of the 191 patients included in the study, 112
responded to the call for clinical examination, presenting with 168 fractures treated with 2.0-mm
miniplates. Among those, 124 fractures were treated
through extraoral approaches. Motor deficits were
observed in 3 patients with 4 fractures (3.41%) from
the 117 fractures in regions related to the facial nerve,
which were treated through 3 (2.56%) extraoral approaches. Two were angle fractures and the other
was a comminuted fracture involving the angle and

Table 2. ASSOCIATED FACIAL FRACTURES

Fractures of the Middle and Upper Third

No. of
Patients

Zygomatic
Complex

38

26

NOE

Zygomatic
Arch

Le Fort
I/II/III

Frontal
Bone

Nasal

Palate

Orbit

19

10

Abbreviation: NOE, naso-orbital-ethmoid.

433

GABRIELLI ET AL

tient had fractures of the right angle and left body,

which were reduced with rotation of the right ascending ramus and lateralization of the condyle, resulting
in some enlargement of that angle and bigonial width,
without altering the occlusion.
Of the 48 condyle fractures stabilized with 2.0-mm
miniplates, there was 1 case of bilateral partial resorption of the fractured fragments, which stabilized after
3 months. Another patient had complete resorption
of the condyle after 3 months and was treated with a
costochondral graft.
FIGURE 3. Infection of angle fractures.

body. Hypoesthesia of the skin or mucosa in the

mental region or lower lip was observed in association with 33 fractures (23.24%) of the 142 fractures
located at the symphysis, body, ramus, and angle.
Thus, 29 patients (31.52%) presented with some kind
of somatosensory disorder.
All sensitivity alterations were noted through objective testing by the examiner. However, when questioned, only 1 patient (0.89%) perceived the sensitivity deficit at the 6-month follow-up. The sensitivity
disturbances were more frequently related with fractures of the body, angle, and symphyseal region. No
postoperative radiograph showed fixation material
impaling the inferior alveolar nerve.
Four patients (4%) among the 100 who were dentate or partially edentulous presented with malocclusion related to the treatment. One of those was not
treated, 2 received selective grinding of teeth and
occlusal guidance with elastics, and 1 went to preoperative orthodontic treatment for mandibular osteotomies. Mean mouth opening for this group of 112
patients was 42.08 mm, ranging from 32 to 56 mm.
Two patients presented with discreet facial asymmetry due to medial or lateral dislocation of the mandibular ramus, both related to angle fractures associated
with body fractures on the opposite side. One patient
with bilateral condyle fractures and a symphysis fracture had an increase in the bigonial width, for a total
of 3 patients with postoperative asymmetries (2.67%).
The quality of the resulting scars for the 124 extraoral
accesses used is shown (Fig 4).
Fibrous union or mobility was found in 4 patients
(3.57%) with 4 fractures (2.38%). Three were angle
fractures, and 1 was a body fracture. However, only 1
of those fractures was mobile (0.59%), and the other
3 were partially consolidated and without mobility.
Two cases of malunion were observed. The first resulted from bilateral condyle fractures associated with
a comminuted symphysis fracture, resulting in medial
inclination of the condyles and asymmetry. One pa-

Discussion
The incidence of 79.06% in male patients with
mandibular fractures is similar to that of other studies,
as well as the mean age of 30.3 years.4-8 That population is economically and socially active and usually
needs to return promptly to normal activity. The main
causes for mandibular fractures were motor vehicle
accidents, followed by assault. Several studies show
physical aggression as the first cause for those
fractures, followed by motor vehicle accidents and
falls.4-6,9,10 The most common site of fracture was the
mandibular angle, as described elsewhere.9,11,12 Ellis
et al4 found the most common sites of fracture to be
the body, condyle, and angle, respectively, depending
on the etiology, with 17.2% of the patients presenting
with other associated facial fractures, mainly in the
zygomatic process. The present study found 19.89%
of patients with associated fractures, the most common being the zygomatic complex fracture, followed
by Le Fort and nasal fractures.
Some authors state that the use of rigid fixation
increases the frequency of postoperative complications. Although in many instances those are due to the
injury sustained or to factors related to the patient,
they are frequently described as resulting from the
method of treatment. It is important to point out that
in many studies the fractures treated with open reduction and internal fixation are the most complex or

FIGURE 4. Aesthetic results of extraoral approaches.

434
the ones that happen to occur in patients who are
either noncompliant or have deleterious habits. Infections are some of the most troublesome complications. Incidence varies from 3% to 32%13-15 when rigid
fixation is used. However, it is very difficult to compare those data because the methods of treatment are
different, as well as the characteristics and behavior of
the studied populations. The literature also disagrees
as to what is considered to be a complication. For
instance, dehiscence and plate exposure are not always considered as complications in centers where
the fixation material is routinely removed.
Infection occurred in 7.85% of the studied fractures, corresponding to 22 fractures in 21 patients
(10.99%). In 13 patients, the infection can be attributed to failure of the fixation system or to the indication for the use of a 2.0-mm miniplate system. Although rigid plates and compression provide more
rigidity than malleable noncompressive plates, the
general incidence of infection found in the present
study (7.85%) is very close to the 6.1% described by
Iizuka et al18 and Iizuka and Lindqvist,5 using the
AO/ASIF technique. It seems that either treatment has
factors that may result in failure and infection. The
infected fractures due to direct failure of the fixation
included 7 comminuted fractures, 3 severely displaced fractures, and 4 displaced fractures, of which 1
was treated late and 1 was extensively exposed intraorally. The literature shows that grossly dislocated
or comminuted fractures need treatment with more
rigid systems.1,6 At least for the comminuted fractures, the problem was caused by inadequate indication for the kind of fixation system, which was used in
those cases due to economic reasons. Of 26 comminuted fractures included in the study, 7 became infected, for an incidence of 26.92%. Bone fragments
were found in 6 infected fractures, most likely related
to the initial comminution and postoperative mobility
and not due to sequestration. In general, the treatment of such patients was incision and drainage of
abscesses, removal of loose fixation material, bone
fragments, and involved teeth. Four patients received
fixation with more rigid methods, and 1 was treated
with intermaxillary fixation. Mandibular reconstruction plates have proved to be an efficient method for
treatment of infected fractures,17-20 whereas instability is directly associated with infection.7,21
When only angle fractures are considered, the infection rate was 18.98%, corresponding to 15 fractures or 68.18% of the total of 22 fractures that became infected. Ellis and Sinn,14 using two 2.4-mm
compression plates in the treatment of angle fractures, found that 32% of them became infected. Ellis
and Karas22 found that 29% of angle fractures developed complications, all related to infection with 1
exception, using two 2.0-mm mini dynamic compres-

MINIPLATE FIXATION OF MANDIBULAR FRACTURES

sion plates. Ellis and Walker23 found a 28% rate of

complications when using 2 noncompressive 2.0-mm
miniplates. Reconstruction plates resulted in a 7.5%
incidence of infection for angle fractures according to
Ellis.24 It is possible that rigidity of the system is not
the only factor that defines the incidence of infection
in the treatment of angle fractures. The angle and
posterior body region present a smaller amount of
bone due to the reduced transverse thickness. The
angle region may be more sensible to the use of
compressive osteosynthesis, screw insertion, vascular
rupture, periosteal elevation, and superficial pressure
by the plates than other mandibular regions, while
offering a smaller surface for interfragmentary contact.
Biomechanical forces that occur during mastication
in the angle region also contribute to a greater incidence of complications.25-27 Several studies suggest
that 2 miniplates should be used when treating mandibular angle fractures, 1 at the base and another at
the superior border, to resist to forces of tension and
compression.21,28,29 Although it is been suggested that
the reduction of bite force at the molar region for
several weeks after rigid fixation in relation to the
normal side would allow use of less fixation,30 the
incidence of forces on the side that was not fractured
will generate considerable load on the affected side.31
Fracture of the plate was seen in 1 of the studied
patients who had bilateral body fractures in an atrophic mandible. Prein1 stated that 2.0-mm miniplates
do not provide adequate stability for atrophic mandibles. Those cases need longer and more rigid plates
that allow insertion of screws in stronger regions
away from the fracture.
The influence of teeth in the line of fracture on
infection is not easy to determine due to interaction
with other factors. Seventeen infected fractures were
associated with the presence of teeth (77.27%). However, in 13 of those the most probable cause for
infection was insufficient fixation. Both situations
probably act interactively. Also, it is not possible to
conclude that infection would not have occurred had
fixation been adequate. Treatment of teeth in the line
of fracture evolved from routine removal32 to removal
of those severely mobile or infected to keeping all
those that are useful, provided that antibiotics are
used.33,34 Third molars involved in angle fractures
receive special attention. Their removal may impair
installation of a tension band plate and sometimes the
stability of the fixation, as well as interfragmentary
contact.1,35
Of 56 third molars involved in angle fractures, 14
were removed during surgical treatment (25%) and 7
were removed postoperatively (12.5%). Only 1 of the
fractures where the tooth was removed during fixation was infected. This was a comminuted fracture,

435

GABRIELLI ET AL

and there was no mobility or loose screws; infection

was limited to the soft tissues and treated by incision
and drainage. Infection was caused either by the presence or removal of the tooth,18 but removal of teeth
in association with an extraoral approach did not
increase the incidence of infection as stated elsewhere.36 Seven third molars were removed postoperatively (12.5%), mostly due to infection occurring in a
period of 7 to 30 days postoperatively. All had dislocated fractures, and in 2 cases the main cause for
infection was inadequate stability. The overall rate of
infection was 7.14% when third molars were removed
and 11.9% when they were not removed. Indications
for removal of third molars include interference with
fracture reduction, fractured roots, pericoronitis,
periodontal disease, and periapical lesions.7,11,37
Of 117 fractures occurring in other dentate regions
of the mandible, only 5 (4.37%) developed infections.
In 2 cases the main cause was failure of the fixation.
The other 3 had soft tissue odontogenic infections
and the fractures were healed, being treated by incision and drainage. One pediatric patient developed a
dentigerous cyst in the premolar region after 6
months. That is one of the possible complications of
mandible fractures in children and is probably due to
the fracture and surgical trauma and not to the fixation unless a screw is driven into a tooth germ.38,39
It is usually considered that fixation with plates and
screws results in increased incidence of inferior alveolar nerve paresthesia. We were not able to precisely
access the preoperative sensitivity deficit. On admission and in the immediate postoperative period, pain,
edema, and lack of patient cooperation or correct
chart information complicate precise evaluation. Postoperative paresthesia was found in 18 dislocated (5
mm), 7 severely dislocated (5 mm), and 18 comminuted fractures. Obviously an association of postoperative paresthesia with displacement and comminution was observed, not necessarily increased by
dislocation greater than 5 mm as described elsewhere.18 Bochlogyros40 reviewed 1,521 mandible fractures and found 7.2% of sensory disturbances, but
only 64% of those fractures occurred in regions related to the mandibular canal. The same happens in
other studies.9,41
Postoperative paresthesia found by objective testing was 31.52% in the present study. When questioned, the great majority of the patients answered
that they did not have alteration of the sensitivity or
that the deficit was so discreet that it was mostly not
perceivable. This behavior has been previously described for mandible fractures and orthognathic surgery.18,42 The described incidence of sensory deficit
runs around 47% after 1 year, with no relation with
the preoperative status,18 and is supposed to be less
when only monocortical screws are used.41,43

Malleable plates are frequently thought to result in

a smaller incidence of postoperative malocclusion
because they are more malleable and easier to
adapt.5,13,44 Four cases of malocclusion were found in
the present study (4.0%). Three presented with anterior fractures, associated with bilateral condyle fractures. In 2 of those cases, it was clear that better
reduction of the lingual cortex and use of stronger
plates to maintain reduction would have prevented
malocclusion.
Facial asymmetry was seen in 2 other patients who
had angle fractures associated with contralateral body
fractures, for a total of 2.67%. In these cases the
problem was very mild. Several combinations of fractures may cause increase in the bigonial distance,
such as symphysis fractures concurrent with condyle
fractures.45 Also, 2.0-mm miniplates may not be sufficient to maintain reduction in some of those cases.
The great majority of patients (97.52%) found no
aesthetic problems related to their extraoral incisions.
Three presented with hypertrophic scars (2.48%), as
may occur in up to 8.3% of young patients.7 Other
studies describe even higher rates of unsatisfactory
scars,46 which certainly can be avoided in most cases
by careful technique but not totally eliminated due to
individual factors.
Of 48 condyle fractures included in the study, 3
developed condylar resorption. These fractures were
severely medially dislocated and disarticulated. Diverse factors may promote condylar resorption, such
as systemic disease, tumors, orthodontic treatment,
and trauma. Stripping of the soft tissue secondary to
trauma or fracture reduction may induce condylar
resorption.47-49 The occurrence of resorption relates
more to soft tissue manipulation during fracture reduction than to the type of fixation.
When using 2.0-mm miniplates to treat condylar
fractures, 2 plates should be used whenever possible.
It is frequent to find bending of the plate postoperatively with some condylar inclination, usually without
clinical relevance or impairment of fracture healing.
That situation occurs even with the use of stronger
plates.50
Results obtained in the present study were not
different from what is described with the use of stronger fixation of mandibular fractures. One has to have
in mind that indications are different and that 2.0-mm
fixation depends much more on the characteristics of
the fracture, behavior of the patient, absence of systemic disease, postoperative care, and adherence to
partial postoperative functional restrictions.

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