ORIGINAL ARTICLE
Surgical Management of Mandibular Angle Fractures
Wei An, DDS,y Aisaiti Ainiwaer, MDS,y Patiguli Wusiman, DDS,y
Gulibusitan Ali, SN,y and Adili Moming, DDS, MDy
Purpose: The study proposed to determine the superiority between
different fixation methods in the mandibular angle fractures
(MAFs) and to evaluate best option for surgeon and patient.
Methods: A systematic review was conducted according to
PRISMA guidelines, examining Medline-Ovid, Embase, and
Pubmed databases. The quality of studies was assessed, and the
odds risk (OR) with its corresponding 95% confidence interval (CI)
was assessed to measure the effect size. Subgroup analyses by
different fracture regions and different miniplate sizes were
performed. Publication bias was measured by a funnel plot.
Results: Twenty-one articles were enrolled in this review: 8
randomized controlled trials , 2 controlled clinical trials, and 11
retrospective studies. There were significant advantages for 3-
dimensional (3D) miniplate (OR ¼ 0.48, P ¼ 0.003, 95% CI,
0.35–0.67) and 1 miniplate (OR 0.38, 95% CI 0.25–0.58,
P < 0.00001). The cumulative OR for locking miniplate was
0.45, showing that the utilizing of locking mini-plate in
management of MAFs decreases postoperative complications
risk by 55% over the use of nonlocking mini-plate.
Conclusions: The results of this review indicated that the use of 3D
miniplate, locking plate, and 1 plate were more advanced to 2
miniplates technique in low incidence of postoperative
complications in the treatment of MAFs.
Key Words: 3-dimensional versus standard miniplate, locking
miniplate versus non-locking miniplate, mandibular angle
fractures, meta-analysis and systematic review, one miniplate
versus two miniplates
(J Craniofac Surg 2018;29: 1702–1708)
From the Department of Oral and Maxillofacial Surgery, The
First Affiliated Hospital of Xinjiang Medical University; and
yStomatological Institute of Xinjiang Uyghur Autonomous Region,
Urumqi, People’s Republic of China.
Received February 3, 2017.
Accepted for publication February 5, 2018.
Address correspondence and reprint requests to Adili Moming, DDS, MD,
Department of Oral & Maxillofacial Surgery, The First Affiliated
Hospital of Xinjiang Medical University, No.137 South Li Yu-shan
Road, New City District 830054 Urumqi, Xinjiang 830054, China;
E-mail: adili928@hotmail.com
W.A. is the first author and A.A. is the co-first author.
This study was financially supported by National Natural Science Funding
of China.
The authors report no conflicts of interest.
Copyright # 2018 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000004568
1702 The Journal of Craniofacial Surgery  Volume 29, Number 7, October 2018
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
A ngle fractures are the most common mandibular fractures,
accounting for the highest percentage of mandibular fractures
in many studies.1 Their management is controversial and is com-
plicated by the anatomic area and complicated biomechanical
relations of the mandibular angle, involving unique anatomical
location of thin cross-sectional area, abrupt alter in curvature,
masticatory force of muscles’ attachment, and the presence of third
molars2,3. Although there is widespread agreement concerning the
demand for quality of surgical reduction and fixation of a mandib-
ular angle fracture (MAF), a variety of different kinds of treatment
philosophies have been described.4,5
The hypothesis was that a single miniplate can provide similar or
better results than the application of 2 miniplates; there will be cost
savings and time saving in surgery necessary to apply the second
bone plate.6
Some studies7,8 have showed no significant differentiation in
outcome between a single plate and 2 miniplates fixation system
using MAFs, whereas Levy et al9 reported that standard mini-plate
provided better outcome than single plate.
Some studies7,8 have reported no difference in outcome when a
single plate was compared with 2 miniplates, whereas Levy et al9
found that 2 plates were better than 1.
Locking 2 miniplates use double-threaded screws, which lock to
the bone and the plate, creating a mini-internal fixation. This results
in a more rigid construction with less distortion of the fracture or
osteotomy, less screw loosening, and less interference with bone
circulation because the plate is not too tightly pressed against the
bone.10 Recently, utilization of 3-dimensional (3D) miniplate has
become popular fixation method in the management of mandibular
fractures, with a growing number of clinical studies3 to challenge
the Champy technique. The basic form is a quadrangular 2  2 hole
square plate; square or rectangular 3  2 or 4  2 hole plates are
also available.
Dimensional plate is a time-saving alternative fixation system
comparing to the standard miniplate; the tension and compression
zones make them simultaneously stabilizing. Moreover, this fixa-
tion method is easy to apply because of malleability of 3D plate, low
profile, and application easily.11
The treatment of MAFs has evolved during the past several
decades, especially fixation management of this area, but debate
continues regarding the best treatment methods. Thus, the aim of
this study was to answer the following question: what fixation
method has the fewest complications in the treatment of MAFs? The
study also provides a clinical database to decide which fixation
approach is the best option for treating MAFs.
MATERIALS AND METHODS
Data Source and Earch Strategy
A systematic review was conducted according to PRISMA
guidelines, examining several electronic databases Medline-Ovid,
Embase, and PubMed databases, Springer Link, and the Cochrane
Library. The retrieving of the key words and combinations of the
following search terms were contained:‘‘conventional’’ OR
‘‘champy’’ OR ‘‘champys’’ OR ‘‘standard’’ OR ‘‘linea oblique’’
The Journal of Craniofacial Surgery  Volume 29, Number 7, October 2018 Different Fixation Method in Management of Mandibular

AND ‘‘3-dimensional’’ OR ‘‘3D’’ OR ‘‘3-D’’ OR ‘‘strut’’ OR ‘‘grid’’)

AND ‘‘mandibular angle’’ OR ‘‘jaw.’’ ‘‘rigid fixation’’OR ‘‘osteo-
synthesis’’OR ‘‘grid mini-plate’’ OR ‘‘matrix mini-plate’’ ‘‘3D strut
miniplate’’ AND ‘‘Champy’’ OR ‘‘locking miniplate versus non-
locking miniplate’’ AND ‘‘one miniplate’’OR‘‘internal rigid fixation
in mandibular angle fractures’’OR‘‘bone plate’’ OR ‘‘osteosynthesis
of mandibular angle fractures.’’

Inclusion and Exclusion Criteria

We reviewed abstracts of all citations and reviewed studies. The
following criteria were used to accept published studies: only the
controlled trials that compared the efficacy of different fixation
system in treatment of MAFs were included, the studies were
included regardless of whether they were any randomized or
quasi-randomized controlled trials (RCTs), controlled clinical trials
(CCTs), or retrospective studies (RSs); the studies had to contain
sufficient raw data for relative ratio (odds risk [OR]) with 95%
confidence intervals (CIs). We excluded the articles according to the
following criteria: in vitro studies comparing to different fixation
method, animal studies, technical and case reports, review reports,
studies using bioabsorbable materials, reports that included infected
or comminuted mandibular fracture, edentulous
mandibles fractures.
FIGURE 1. Study screen process.

Data Extraction and Quality Assessment

Eligibility of all studies reviewed from the databases was
independently extracted by 2 investigators utilizing a predefined
model, which included the relevant information: name of the first
author, exact time of publication, regions of the population, age and
sex composition of patients, sample sizes, and study outcomes.
Final decision with disagreement was handled through a discussion
involving a third investigator.
Statistical Analysis
Dichotomous variables (the incidence of overall complication,
postoperative infection rate, and operation time) were analyzed
using RevMan5.26 software, which was provided by Cochrane
Collaboration. P < 0.10 was considered statistically significant.
Heterogeneity was checked by x2 test. If the results of the
trials had heterogeneity, a random-effects model was used for
meta-analysis. Otherwise, a fixed-effects model was used. The
result was expressed with OR for the categorical variable and
95% CIs.
RESULTS
Literature Search
The literature selective design of process is summarized in
Figure 1. A total of 1576 studies were identified from preliminary
search. After initial screening of duplicate publications and remov-
ing the irrelevant articles via title browsing and abstract reading,
704 articles were excluded. Of the resulted 872 studies, 545 were
excluded for not being related to the topic. Base on the remaining
article of full topic shows the exclusion of 306 articles because they
did not meet the standard of defined inclusion criteria, subsequently
21 studies were included in qualitative and quantitative synthesis: 8
RCTs, 2 CCTs, and 11 RSs. Detailed characteristics of the included
studies are shown in Table 1.12–28 A total of 1993 patients were
enrolled in 21 studies: 9 studies compared the 3D plate with the
standard 2-miniplate technique, 10 studies compared the 1 mini-
plate with the 2 miniplates, 2 studies compared the locking plate
with the non-locking at varying follow-up periods.
Quality Assessment
Each trial was evaluated for risk of bias, and the scores are
assessed in Table 2. Two studies were judged to be at high risk of
bias, whereas 3 studies were considered at moderate risk of bias, and
7 studies were showed at low risk of bias.
Results of Individual Studies
Three-Dimensional Versus Standard Mini-plate
Nine studies compared the 3D plate with the conventional 2
miniplates technique at varying follow-up periods. There was
statistically significant difference in hard ware failure
(P ¼ 0.006), whereas there was no obvious difference concerning
postoperative complication of infection, wound dehiscence, aloc-
clusion, nonunion/malunion, paresthesia, and trismus. The cumu-
lative OR analysis revealed a statistically significant superiority for
the use of 3D miniplate over 2 miniplates when the incidence of all
postoperative complications was taken into consideration; also this
advantage reached statistical significance (OR ¼ 0.38, 95% CI
0.25–0.58; P ¼ 0.001). The test of heterogeneity revealed the
homogeneity (x2 ¼ 17.84, df ¼ 30, P ¼ 0.001; I2 ¼ 0%), also the
test for subgroup differences (x2 ¼ 6.93, df ¼ 6, P ¼ 0.33;
I2 ¼ 13.4%). The cumulative OR was 0.38, indicating that the
utilization of 3D miniplate system of MAFs decreases the risk
for postoperative complications by 62% compared with the use of
standard miniplate (Fig. 2).
One Plate Versus 2 Miniplates
Ten studies reported the incidence of postoperative complica-
tions when 1 plate was compared with the application of 2 mini-
plates. There was significant difference in postoperative scarring
(P ¼ 0.006), whereas there were no statistically significant differ-
ences regarding infection, wound dehiscence, and paresthesia. The
cumulative analysis of OR revealed a statistically significant supe-
riority for the use of one mini-plate over 2 mini-plates as the
incidence of all postoperative complications was considered (OR
0.38, 95% CI 0.25–0.58; P < 0.00001 (Fig. 3). The test of hetero-
geneity revealed homogeneity (x2 ¼ 29.33, df ¼ 24, P < 0.00001;

# 2018 Mutaz B. Habal, MD 1703

Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 TABLE 1. Comparison Between Fixation Methods (Lag Screw, 3D Plate, 1 and 2 Conventional Miniplates) in Mandibular Angle Fractures

1704
Year Study Sex Mean Age Follow-up MF Fixation Mean Length of
An et al

Study Published Design (M/F) (Range), y Patients (n) Period Methods Operation, min MFs Region of MFs

Singh et al28 2012 RCT (G1, G2): 4/46 (G1, G2): 30.4 G1: 25; G2:25 1, 4, 8, 12 wk G1: Single 2.0-mm 4-hole G1: 49.57; 56 Angle (n ¼ 20), parasymphysis
miniplateat the G2:43 (n ¼ 35), symphysis (n ¼ 1)
externaloblique line
oronthelateral cortex
(n ¼ 10); G2: single
rectangular 2.0-mm 6-hole
3D miniplate (n ¼ 10)
Vineeth et al34 2012 RCT NM (G1, G2): 19-51 G1: 10; G2: 10 1 day, 1 wk, 1 m, G1 Single 2.0-mm 4-hole NM 29 Angle (n ¼ 20), additional
3 mo miniplateat the fractures (n ¼ 9; G1, n ¼ 5; G2,
externaloblique line n ¼ 4)
(n ¼ 10); G2: single
rectangular 2.0-mm 6- or 8-
hole 3D miniplate (n ¼ 10)
Xue et al31 2013 RCT (G1, G2): 18/0 G1: 28; G2: 28 G1: 6; G2: 7 1–2 wk, 4–6 wk, G1: Single 2.0-mm 4-hole G1: 42; G2: 102 22 Angle (n ¼ 13), parasymphysis
6 mo miniplateat the (n ¼ 8), subcondylar (n ¼ 1)
externaloblique line
(n ¼ 7); G2: single curved
2.0-mm 10-hole 3D
miniplate (n ¼ 6)
Höfer et al23 2012 RS (G1, G2): 52/8 (G1, G2): (31.1) G1: 30; G2: 30 7, 14, 28 days, G1 Single 2.0-mm 6-hole G1: 89; G2: 81 90 Angle (n ¼ 60), (G1, G2): body
and 3, 6, 12 miniplateat the (n ¼ 25) ascending ramus
mo externaloblique line (n ¼ 5)
(n ¼ 30); G2: single
rectangular 2.0-mm 4-hole
3D miniplate (n ¼ 30)
Guy et al22 2013 RS G1: 20/2; G2: 64/4 (G1, G2): 28 G1: 22; G2: 68 G1: 47 days; G2: G1 One or two 2.0-mm 4-hole G1: 232.2; G2: 161 Angle (n ¼ 96), parasymphysis
55 days miniplate (n ¼ 22); G2: 219.5 (n ¼ 41), body (n ¼ 11),
single curved 2.0-mm 8- condyle (n ¼ 5), coronoid
hole 3D miniplate (n ¼ 68) (n ¼ 2), ramus (n ¼ 6)
Moore et al26 2013 RS G1: 27/5; G2: 59/13 NM (31) G1: 32; G2: 72 NM G1: Single 2.0-mm 4- or 6- NM 168 Angle (n ¼ 106), parasymphysis
hole miniplate at the (n ¼ 51), body (n ¼ 11)
external oblique line
(n ¼ 33); G2: single curved
2.0-mm 8-hole 3D
miniplate (n ¼ 73)
Moraissi et al3 2014 RCT (G1, G2): 16/4 G1: 25.5  6.8; G1: 10; G2: 10 1 wk, 1, 2, 3, G1: single 2.0-mm standard G1: 39.7  9.1; NM NM
The Journal of Craniofacial Surgery

G2: 27  0.9 and 6 mo miniplate; G2: 1.0-mm G2: 33  4.6



miniplate (n ¼ 73)
Elsayed et al21 2015 RS G1: 7/3; G2: 7/3 G1: 26.1  2.34; G1: 10; G2: 10 1, 2, 3, 4 wk; 3 G1: single 2.0-mm locking G1: 36 G1: (n ¼ 2) angle, G2: (n ¼ 3)
G2: 27  0.9 and 6 mo miniplate; G2:single rigid 33.20  2.44; angle (symphyseal þ angle
2.3-mm plate G2: G1:[n ¼ 1] G2: [n ¼ 1])
42.0  2.32 (parasymphyseal þ angle G1:
[n ¼ 4], G2: [n ¼ 3])
)body þ angle G1: [n ¼ 3], G2:
[n ¼ 3]) ( subcondylar G1:
[n ¼ 1], G2: [n ¼ 1]
Levy et al25 1991 RS (G5 þ G6): 52:9 (G5 þ G6): 18– G5: 19 G6: 22 1, 2, 4, 6, G5: single 2-mm miniplate; NM 99 Angle (n ¼ 63), parasymphysis
47 (28.6) 12 wk G6: two 2-mm miniplates (n ¼ 22), body (n ¼ 5),
subcondyle (n ¼ 5)
Schierle et al8 1997 RCT NM NM G5: 16; G6: 15 NM G5: single 2-mm miniplate; NM 45 Angle (n ¼ 38), parasymphysis
G6: two 2-mm miniplates (n ¼ 5), condyle (n ¼ 2)
Siddiqui et al8 2007 RCT (G5 þ G6): 75:10 (G5 þ G6): 17– G5: 36; G6: 26 12 wk G5: single 2-mm miniplate; NM NM Mandibular angle
57 G6: two 2-mm miniplates

# 2018 Mutaz B. Habal, MD

Volume 29, Number 7, October 2018

Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 #
TABLE 1. (continued )

Year Study Sex Mean Age Follow-up MF Fixation Mean Length of

Study Published Design (M/F) (Range), y Patients (n) Period Methods Operation, min MFs Region of MFs

Mehra et al27 2008 RS NM (G5 þ G6): 17– G5: 76; G6: 57 8–64 wk (12.3 G5: single 2-mm miniplate ; G5: 34; G6: 163 Mandibular angle
57 (24.8) wk) G6: two 2-mm miniplates 119.6
Danda et al20 2010 RCT G5: 21:6; G6: 23:4 G5: 32.4 (18– G5: 27; G6: 27 2 wks, arch bars G5: single 2-mm miniplate; NM NM Mandibular angle
43); G6: 29.6 for 4 wk G6: two 2-mm miniplates
(21–49)
Seemann et al29 2010 RS (G5 þ G6): 295:63 Men: 29.67; G5: 95; G6: 170 NM G5: single 2-mm miniplate; NM 335 Mandibular angle
women: 49.07 G6: two 2-mm miniplate

2018 Mutaz B. Habal, MD

24
Kumar et al 2011 RS (G5 þ G6): 63:18 (G5 þ G6): 16– G5: 50 G6: 33 3 mo G5: single anterior plate, NM 80 Mandibular angle: 80
The Journal of Craniofacial Surgery

62 (26.6) single ventral plate; G6:



two plates
Ellis et al6 2010 RS G5: 372/45; G6: 236/29 G5: 28.3 (13– G5: 417; G6: 265 (G5): 146.11 G5: 1 strong plate; G6: two NM 682 (G5): Angle (n ¼ 119),
54) ; G6: 27.6 days; (G6): 2.0-mm miniplates parasymphysis/body (n ¼ 107),
(14–57) 139.56 days condyle (n ¼ 119); (G6): angle
(n ¼ 114), parasymphysis/body
(n ¼ 71), condyle (n ¼ 80)
Yazdani et al32 2013 CCT (G5 þ G6): 73:14 (G5 þ G6): 16– G5: 45; G6: 42 1, 2 wk; 2, 3, 6 G5: single 2-mm miniplate; NM NM Mandibular angle
66 and 12 mo G6: two 2-mm miniplates
Yang et al33 2015 RCT G3: 17/13; G4: 18/12 G3: 35.4; G4: G3: 30; G4: 30 6 mo G3: 2.0-mm locking plate NM 60 Mandibular angle
37.3 system; G4: 2.0-mm non-
locking plate system
Cillo et al19 2014 CCT (G5 þ G6): 31:2 (G5 þ G6): 18– G5: 33; G6: 33 8 wk G5: single 2-mm miniplate; NM 33 Mandibular angle
48 (25.2) G6: two 2-mm miniplates
Bhatt et al18 2015 RS G3: 15/1 G4: 19/1 G3: 29.5 þ 10.9; G3: 16; G4: 20 NM G3: 2.0-mm locking plate NM 36 G7: 4 angle fractures, 12
G4: system; G4: 2.0-mm non- combined fractures; G8: 8 angle
26.4 þ 10.1 locking plate system fractures, 13 combined
Volume 29, Number 7, October 2018

fractures
Tairi et al30 2015 RS G1: 6/2; G2: 6/2 G1: 25; G2: 24 G1: 8; G2: 8 1, 3, and 6 mo G1: 2 miniplates fixation; G2: NM 16 Mandibular angle (16)
3D miniplate

MF, mandibular fracture; NM, not mentioned; RCT, randomized controlled trials; CCT, controlled clinical trials; RS, retrospective studies; G1, group1 (standard miniplates); G2, group 2 (3D miniplates); G3, locking miniplate; G4,
non-locking miniplate; G5, 1 miniplate; G6, 2 miniplates.

1705
Different Fixation Method in Management of Mandibular

Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
An et al The Journal of Craniofacial Surgery  Volume 29, Number 7, October 2018

TABLE 2. Results of the Quality Assassment

Random Selection Defined Inclusion/ Loss of Validated Statistical Estimated Potential
Authors Published in Population Exclusion Criteria follow-up Measurement Analysis Risk of Bias

Levy et al24 1991 No Yes Yes Yes Yes Moderate

Schierle et a8 1997 Yes Yes Yes Yes Yes Low
Siddiqui et al8 2007 Yes Yes Yes Yes Yes Low
Mehra et al26 2008 No Yes Yes Yes Yes Moderate
Danda et al19 2010 Yes Yes Yes No Yes Moderate
Seemann et al28 2010 No Yes Yes Yes No Moderate
Ellis et al6 2010 No Yes Yes Yes Yes Moderate
Kumar et al23 2011 No Yes Yes Yes Yes Moderate
Singh et al27 2012 Yes Yes Yes Yes Yes Low
Höfer et al22 2012 No Yes Yes Yes Yes Moderate
Vineeth et al33 2013 Yes Yes Yes Yes Yes Low
Xue et al30 2013 Yes Yes Yes Yes Yes Low
Guy et al21 2013 No Yes No Yes Yes Moderate
Moore et al25 2013 No Yes No No Yes High
Yazdani et al31 2013 Yes Yes Yes Yes Yes Low
Moraissi et al3 2014 Yes Yes Yes Yes Yes Low
Cillo et al18 2014 No Yes Yes Yes Yes Moderate
Yang et al32 2015 Yes Yes Yes Yes Yes Low
Bhatt et al17 2015 No Yes Yes Yes Yes Moderate
Elsayed et al20 2015 No No Yes Yes Yes High
Tairi et al29 2015 No Yes Yes Yes Yes Moderate

I2 ¼ 18%), also the test for subgroup differences (x2 ¼ 6.09, df ¼ 3,

P ¼ 0.11; I2 ¼ 50.7%). The cumulative OR was 0.38 revealing that
the use of one plate fixation system of MAFs decreases postopera-
tive complications risk by 62% compared with the use of 2 mini-
plates.

Locking miniplate Versus Non-locking Miniplate

Two studies comparing locking miniplate and non-locking
miniplates assessed postoperative complications. The cumulative
overall analysis of all complications revealed obvious superiority
for the locking miniplate technique as all postoperative complica-
tions were taken into consideration (OR ¼ 0.45; 95% CI, 0.17–
1.18; P ¼ 0.10). The test of heterogeneity indicated homogeneity
(x2 ¼ 3.63, df ¼ 1, P ¼ 0.06; I2 ¼ 72%). The cumulative OR was
0.45, showing that the using locking miniplate in the management
of MAFs decreases postoperative complications risk by 55% com-
pared with using non-locking miniplates (Fig. 4).

Sensitivity Analysis and Publication Bias

The cumulative analysis after the exclusion of studies with a
high risk for bias did not change the overall main results (Fig. 5).
The publication bias for the outcome of complications, which was
involved in 9 studies, was estimated. As revealed in the funnel plot
(Fig. 6), the obvious asymmetry was not observed, indicating the
absence of publication bias in this meta-analysis.

FIGURE 2. Forest plots, 3D miniplate versus standard miniplate in mandibular

angle fractures (postoperative complications). CI, confidence interval; M-H, the FIGURE 3. Forest plots, one miniplate versus 2 miniplates in mandibular angle
Mantel-Haenszel. fractures complications. CI, confidence interval; M-H, the Mantel-Haenszel.

1706 # 2018 Mutaz B. Habal, MD

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The Journal of Craniofacial Surgery  Volume 29, Number 7, October 2018
FIGURE 4. Forest plots, locking mini-plate versus non-locking miniplates in
mandibular angle fractures (postoperative complications). CI, confidence
interval; M-H, the Mantel-Haenszel.
DISCUSSION
This meta-analysis included a set of 21 studies to evaluate the
efficiency of the different miniplate on the treatment of MAFs. The
study comparing 1 miniplate with the application of 2 miniplates
revealed that there was statistically significant difference among the
different fixation method, the advantage of 1 miniplate over 2
miniplates (OR ¼ 0.38; P < 0. 00001), showing that using 1 plate in
the management of MAFs decreases postoperative complications
risk by 62% over the use of 2 miniplates.
The high postoperative complication of 2 mini-plate fixation
system may be ascribed to muscle attachment and more periosteal in
the anatomical region of angle, which would be detrimental both
would healing and blood supplement, also oral condition of con-
tamination with oral bacteria, all these factors may increase the
postoperative complication with wound cure.
Regarding to the 3D plate versus 2 miniplates, the meta-analysis
revealed that there was statistically significant difference among the
different fixation system; also it was showed that using 3D mini-
plates in the management of MAFs decreases postoperative com-
plications risk by 62% over the use of 2 miniplates. The 3D
miniplate technique in the region of the superior and inferior
borders facilitates the reduction and stabilization.31 Vineeth
et al32 showed that the 3D titanium miniplates revealed better
initial interfragmentary stability comparing to single titanium mini-
plates in their study. Another study results of the in vitro study33
observe that the 3D miniplate technique has more favorable bio-
mechanical behavior comparing to the standard miniplate. The
better interfragmentary stability may have had an influence on
the decreasing of some postoperative complications found with the
using of 3D miniplate fixation system in the management of MAFs.
With reference to locking miniplate versus non-locking mini-
plates, there was no statistically significant advantage of locking
FIGURE 5. Forest plots, 3D plate versus standard mini-plate in mandibular
angle fractures (postoperative complications). CI, confidence interval; M-H, the
Mantel-Haenszel.
# 2018 Mutaz B. Habal, MD
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Different Fixation Method in Management of Mandibular
FIGURE 6. Funnel plot—publication bias according to the report.
miniplate over non-locking miniplates (OR ¼ 0.45; P ¼ 0.10),
showing that using locking miniplate in the management of MAFs
decreases the risk for postoperative complications by 55% over the
use of non-locking miniplates. In addition, the low postoperative
MAF rate of using locking miniplates also showed that the locking
mini-plate is a prospective fixation system in the treatment of
maxillofacial angle fractures.
The present study indicates the 3D, 1 miniplate, locking mini-
plate has the fewest complication in the treatment of MAFs, and
also provides scientific data to enable to surgeons to make evidence-
based decisions regarding the best technique. But the main disad-
vantage of the locking system has been the cost. The extra cost to
the patient will be considerable.
CONCLUSIONS
The results of this meta-analysis revealed that using 3D miniplate,
locking plate, and 1 plate is advantageous over 2 miniplates fixation
system in low incidence of postoperative complications rate in the
management of MAFs.
REFERENCES
1. Aleysson PO, Abuabara A, Passeri LA. Analysis of 115 mandibular
angle Fractures. J Oral Maxillofac Surg 2008;6:66–73
2. Al-moraissi EA, Ellis E III. What method for management of unilateral
mandibular angle fractures has the lowest rate of postoperative
complications? A systematic review and meta-analysis. J Oral
Maxillofac Surg 2014;72:2197–2211
3. Al-Moraissi EA, El-Sharkawy TM, El-Ghareeb TI, et al. Three-
dimensional versus standard miniplate fixation in the management of
mandibular angle fractures: a systematic review and meta-analysis. Int J
Oral Maxillofac 2014;43:708
4. Chrcanovic BR. Fixation of mandibular angle fractures: clinical studies.
Oral Maxillofac Surg 2014;18:123–152
5. Chrcanovic BR. Fixation of mandibular angle fractures: in vitro bio-
mechanical assessments and computer-based studies. Oral Maxillofac
Surg 2013;17:251–268
6. Ellis E III. A prospective study of 3 treatment methods for isolated
fractures of the mandibular angle. J Oral Maxillofac Surg
2010;68:2743–275422
7. Ellis E III. Treatment methods for fractures of the mandibular angle. Int
J Oral Maxillofac Surg 1999;28:243–252
8. Schierle HP, Schmelzeisen R, Rahn B, et al. One- or two plate fixation of
mandibular angle fractures? J Craniomaxillofac Surg 1997;25:162–168
9. Levy FE, Smith RW, Odland RM, et al. Monocortical Mini-plate
fixation of mandibular angle fractures. Arch Otolaryngol Head Neck
Surg 1991;117:149–154
1707
An et al The Journal of Craniofacial Surgery
10. Alpert B, Gutwald R, Schmelzeisen R. New innovations in
craniomaxillofacial fixation: the 2.0 lock system. Keio J Med
2003;52:120–127
11. Guimond C, Johnson JV, Marchena JM. Fixation of mandibular angle
fractures with a 2.0-mm 3-dimensional curved angle strut plate. J Oral
Maxillofac Surg 2005;63:209
12. Almoraissi EA, Ellis E III. What method for management of unilateral
mandibular angle fractures has the lowest rate of postoperative
complications? a systematic review and meta-analysis. J Oral
Maxillofac Surg 2014;72:2197–2211
13. Farmand M. The 3-dimensional plate fixation of fractures and
osteotomies. Facial Plast Surg 1995;3:39–56
14. Guimond C, Johnson JV, Marchena JM. Fixation of mandibular angle
fractures with a 2.0-mm 3-dimensional curved angle strut plate. J Oral
Maxillofac Surg 2005;63:209–214
15. Vineeth K, Lalitha RM, Prasad K, et al. A comparative evaluation
between single noncompression titanium miniplate and three
dimensional titanium miniplate in treatment of mandibular angle
fracture—a randomized prospective study. J Craniomaxillofac Surg
2013;41:103–109
16. Alkan A, Celebi N, Ozden B, et al. Biomechanical comparison of
different plating techniques in repair of mandibular angle fractures. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:752–756
17. Bhatt K, Arya S, Bhutia O, et al. Retrospective study of mandibular
angle fractures treated with three different fixation systems. Natl J
Maxillofac Surg 2015;6:31–36
18. Cillo J, Ellis E III. Management of bilateral mandibular angle fractures
with combined rigid and nonrigid fixation. J Oral Maxillofac Surg
2014;72:106–111
19. Danda AK. Comparison of a single noncompression miniplate versus
two noncompression miniplates in the treatment of mandibular angle
fractures: a prospective, randomized clinical trial. J Oral
MaxillofacSurg 2010;68:1565–1567
20. Elsayed SA, Mohamed FI, Khalifa GA. Clinical outcomes of three
different types of hardware for the treatment of mandibular angle
fractures: a comparative retrospective study. Int J Oral Maxillofac Surg
2015;44:1260–1267
21. Guy WM, Mohyuddin N, Burchhardt D, et al. Repairing angle of the
mandible fractures with a strut plate. JAMA Otolaryngol Head Neck
Surg 2013;139:592–597
1708 # 2018 Mutaz B. Habal, MD
Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 29, Number 7, October 2018
22. Höfer SH, Ha L, Ballon A, et al. Treatment of mandibular angle frac-
tures—line ablique plate versus grid plate. J Craniomaxillofac Surg
2012;40:807–811
23. Kumar S, Prabhakar V, Rao K, et al. A comparative review of treatment
of 80 Mandibular angle fracture fixation with miniplates using three
different techniques. Indian J Otolaryngol Head Neck Surg
2011;63:190–192
24. Levy FE, Smith RW, Odland RM, et al. Monocortical miniplate fixation
of mandibular angle fractures. Arch Otolaryngol Head Neck Surg
1991;117:149–154
25. Moore E, Bayrak S, Moody M, et al. Hardware removal rates for man-
dibular angle fractures: comparing the 8-hole strut and Champy plates.
J Craniofac Surg 2013;24:163–165
26. Mehra P, Murad H. Internal fixation of mandibular angle fractures:
acomparison of 2 techniques. J Oral Maxillofac Surg 2008;66:
2254–2260
27. Singh V, Puri P, Arya S, et al. Conventional versus 3-dimensional
miniplate in management of mandibular fracture: a prospective
randomized study. Otolaryngol Head Neck Surg 2012;147:
450–455
28. Siddiqui A, Markose G, Moos K, et al. One miniplate versus two in the
management of mandibular angle fractures: a prospective randomized
study. Br J Oral Maxillofac Surg 2007;45:223–225
29. Seemann R, Schicho K, Wutzl A, et al. Complication rates in the
operative treatment of mandibular angle fractures: a 10-year
retrospective. J Oral Maxillofac Surg 2010;68:647–650
30. Tairi NH, Shoushan MM, Saad Khedr MM, et al. Comparison of three-
dimensional plate versus double miniplate osteosynthesis for treatment
of unfavourable mandibular angle fractures. Tanta Dental J 2015:
1687–8574
31. Xue AS, Koshy JC, Wolfswinkel EM, et al. A prospective study of strut
versus miniplate for fractures of mandibular angle. Craniomaxillofac
Trauma Reconstr 2013;6:191–196
32. Yazdani J, Tahen Talesh K, Kalantar Motamedi MH, et al. Mandibular
angle fractures: comparison of one miniplate vs. two miniplates.
TraumaMon 2013;18:17–20
33. Yang L, Patil P M. Comparative evaluation of 2.0 mm locking plate
system vs 2.0 mm non-locking plate system for mandibular angle
fracture fixation: a prospective randomised study. Eur Rev Med
Pharmacol Sci 2015;19:552–556