Int. J. Oral MaxilloJhc. Surg.

1999; 28:243~52 Copyright 9 Munksgaard 1999

Printed flz Denmark. All rights reserved
Intemadona]Joumal of
Oral8r
Maxill@cial Surgery
ISSN 090t-5027

Leading article
E d w a r d Ellis III
Treatment methods for Oral and Maxillofacial Surgery, The University
of Texas Southwestern Medical Center,
Dallas, Texas, USA

fractures of the mandibular

angle
E. Ellis III. Treatment methods for fractures of the mandibular angle. Int. J. Oral
Maxillofac. Surg. 1999, 28." 243~52. 9 Munksgaard, 1999

Abstract. Fractures of the mandibular angle are plagued with the highest rate of
complication of all mandibular fractures. Over the past 10 years, various forms
of treatment for these fractures were performed on an indigent inner city
population. Treatment included: 1) closed reduction or intraoral open reduction
and non-rigid fixation; 2) extraoral open reduction and internal fixation with an
AO/ASIF reconstruction bone plate; 3) intraoral open reduction and internal
fixation using a solitary lag screw; 4) intraoral open reduction and internal
fixation using two 2.0 mm mini-dynamic compression plates; 5) intraoral open
reduction and internal fixation using two 2.4 mm mandibular dynamic
compression plates; 6) intraoral open reduction and internal fixation using two
non-compression miniplates; 7) intraoral open reduction and internal fixation
using a single non-compression miniplate; and 8) intraoral open reduction and
internal fixation using a single malleable non-compression miniplate. This paper
reviews the results of those modes of treatment when used for the same patient
population at one hospital. Results of treatment show that, in this patient
Key words: mandibular fracture; bone plates;
population, the use of either an extraoral open reduction and internal fixation fracture fixation.
with the AO/ASIF reconstruction plate or intraoral open reduction and internal
fixation, using a single miniplate, are associated with the fewest complications. Accepted for publication 24 January 1999

Fractures of the mandibular angle rep-
resent the largest percentage of man-
dibular fractures in many studies. The
etiology of the injury has something to
do with the location of the mandible
that fractures. Fractures sustained in
altercations show a high incidence of
fractures of the angle of the man-
dible 33'4~176 The prevailing
thought is that a blow to the lateral
portion of the mandible causes a frac-
ture at that point, and commonly a
fracture on the opposite body/symphy-
sis region.
Why is the angle of the mandible
commonly associated with fractures?
There are several proposed reasons that
include: 1) the presence of third molars;
2) a thinner cross-sectional area than
the tooth-bearing region; and 3) bio-
mechanically the angle can be con-
sidered a "lever" area. Several authors
have implicated the presence of third
molars, especially impacted third mo-
lars, as a reason for mandibular frac-
tures occurring in the region of the
angle. In fact, some have recommended
prophylactic removal of third molars to
eliminate their weakening effect in the
angle region, in hopes of preventing
fractures from occurring 1,2,39'61'64'68.
While this seems an extreme stance on
the issue, there is scientific evidence in-
dicating that third molars do weaken
the angle of the jaw and are associated
with fractures more commonly than
when no tooth is present. For instance,
a study by REITZlK et al. s3 found mon-
key mandibles with unerupted third
molars fractured at 60% of the force re-
quired when no tooth was present, Clin-
ical investigations have shown that pa-
tients with third molars present are
more likely to sustain fractures of the
angle than when no tooth is pres-
ent s6,7~ Further, the amount of space
occupied by the third molar was found
to directly relate to weakness in that re-
gion of the mandible 56,
One would logically expect fractures
to occur at points of greatest weakness
in a structure. One would also logically
expect that thinner cross-sectional areas
of a structure would be weaker than
those areas with greater cross-sectional
areas. A study by SHVBERT et al. 63 has
shown that the region of the mandibu-
lar angle is thinner than both the bone
of the body region located more anteri-
orly, and the bone of the ramus located
244 Ellis
more posteriorly. Thus, a given force
applied to the lateral aspect of the man-
dible might be expected to fracture at
the region with the smallest cross-sec-
tional area the angle of the mandible.
Combine this with the fact that the
angle of the mandible is where there is
an abrupt change in shape from hori-
zontal to vertical rami, which would im-
ply that this region might be subjected
to more complex forces than a more lin-
ear geometric shape, and one can begin
to understand why fractures occur in
this location.
Fractures of the mandibular angle
represent an important clinical chal-
lenge because their treatment is plagued
with the highest postsurgical compli-
cation rate of all mandibular frac-
tures 16,34,36,s9,72. Even traditional treat-
ment methods have a high complication
rate in some patient populations49.
With the introduction and popularity
of plate and screw fixation over the past
30 years, a number of fixation methods
have been advocated for the treatment
of fractures occurring through the angle
of the mandible. Many of these tech-
niques are seemingly disparate. For in-
stance, the AO/ASIF originally felt that
plate and screw fixation should provide
sufficient rigidity to the fragments to
prevent interfragmentary mobility dur-
ing active use of the mandible66,67.
LUItR42 similarly recommended large
bone plates, usually with compression,
fastened with bicortical bone screws to
provide such rigidity. Primary bone
union, which necessitates absolute im-
mobility of fragments, is the goal of
treatment of mandibular fractures by
these surgeons.
In 1973, MICHELET et al. 45 reported
on the treatment of mandibular frac-
tures using small, easily bendable non-
compression bone plates, placed trans-
orally, attached with monocortical
screws. The application of this tech-
nique was a seeming dichotomy to the
more widely accepted dictum of rigid
fixation, and sparked a revolution in the
treatment of facial fractures. CHAMPYet
al.8 12 performed several investigations
with a "miniplate" system to validate
the technique, in their experiments,
they determined the "ideal lines of os-
teosynthesis" in the mandible, or the
locations where bone plate fixation
should provide the most stable means
of fixation. For fractures of the man-
dibular angle, the most effective plate
location was found to be along the su-
perior border of the mandible. Because
the bone plates were small and the
screws inserted monocortically, fixation
could be applied in this most mechanic-
ally advantageous area without damag-
ing teeth. Unlike the AO/ASIF sur-
geons and LUHR, absolute immo-
bilization of bone fragments and
primary bone union was deemed un-
necessary. Clinical studies since have
proven the usefulness of this tech-
nique7,24,26,27,29,31,47,51,73
Questions about the degree of sta-
bility provided by these "mini-plates"
have become a point of contention
among surgeons. RAVEH et al. 52,
LUHR44 and AO/ASIF advocates 4 do
not feel that the plates offer adequate
stabilization of the fracture to eliminate
the need for intermaxillary fixation.
Other surgeons who routinely used the
more rigid AO/ASIF plates began to re-
lent and use miniplates26'27.
Unfortunately, whether or not one
method is "superior" to another is diffi-
cult to determine. Studies in the litera-
ture vary widely in the rates of compli-
cation reported when treating fractures
of the angle. For instance, LUHR &
HAUSMANN43 report a 0.9% rate of com-
plications in 352 patients treated by
compression plates for fractures of the
angle, whereas ELLIS & SINN22 report a
32% rate of complication in 65 patients
treated with compression plates for
angle fractures. IIZUKA & L1NDQVIST35
reported a 6.6% rate of infection and a
14% rate of malocclusion for 121 frac-
tures of the angle. Analysis in that study
showed that complications were most re-
lated to the use of compression and two
points of fixation.
How can rates of complication be so
varied? There are several problems when
one attempts to compare treatment
methods for fractures of the mandibular
angle. The first difficulty is that there are
few studies that restrict their focus to
fractures of the mandibular angle. Most
studies evaluating results for mandibular
fractures include fractures in all regions
of the mandible, making it difficult to de-
termine the actual rate of complication
for angle fractures. Another problem is
that treatment in one country may be
very different from treatment in another.
For instance, patients treated for man-
dibular fractures in some of the Euro-
pean countries may spend 7 21 days in
hospital after surgery. In the United
States, they are usually discharged the
same or the next day. It is therefore
doubtful that the quality and quantity of
postsurgical care is similar. Studies also
vary in the etiology of the injury. Studies
from the United States generally have
samples drawn from large inner-city hos-
pitals where most of the injuries result
from interpersonal violence, i n many
European, Middle Eastern and Asian
studies, motor vehicle-related injuries
are more common. Hand in hand with
the cause of the injury is the socioecon-
Omic status of the patients. Those in-
jured by interpersonal violence and
treated in major inner-city hospitals in
the United States tend to be poor, with
poor oral hygiene and a poor state of
dentition. Those patients whose frac-
tures are sustained in motor vehicle acci-
dents, sports or in bicycle accidents tend
to be a higher socioeconomic group and
are more concerned with oral and gen-
eral health. There are also great differ-
ences in the literature in what constitutes
a complication. In countries where rout-
ing removal of fixation devices is com-
mon, soft tissue dehiscence with plate ex-
posure may not be counted as a compli-
cation because the plate will be removed
anyway. In the United States, where
plate removal is not routine, any un-
planned intervention should be con-
sidered a complication. Another major
variable is in the number of surgeons in-
volved in the operative intervention. Be-
cause of these factors and a host of
others, it becomes difficult to accurately
assess treatment results with different
fixation techniques.
The following presents the experience
of one faculty surgeon treating fractures
of the mandibular angle at one insti-
tution, with a consistent patient popu-
lation, using eight different techniques.
While a number of residents were in-
volved in the surgeries, the same faculty
member (E.E.) was present for over
95% of the actual open part of the oper-
ations.
Methods
Over the past 10 years, various methods of
treatment for fractures of the angle of the
mandible have been studied at Parkland
Memorial Hospital in Dallas, Texas. The con-
tinuing quest for a simple but effective tech-
nique drove us to use different modes of treat-
ment and to examine their efficacy. The fol-
lowing study relates our experience with
several accepted methods for treating frac-
tures of the mandibular angle19 25,49,51. The
first two methods, closed reduction with or
without non-rigid fixation, and the use of the
AO/ASIF reconstruction plate, were retro-
spective studies. All others were prospectivein
their data collection.With the exception of the
extraoral approach used in those patients

treated with the AO/ASIF reconstruction
plate, all techniques were intraoral, with the
exception of transfacial trocar instrumen-
tation.
The population in these studies was largely
inner-city indigent patients with poor den-
titions and poor oral hygiene. The majority
of the cases occurred in males (approximate-
ly 85%). The racial/ethnic breakdown was
approximately 50% African-Americans, 30%
Non-Hispanic Caucasians, and 20% Hispan-
ic. The average age of the patients was ap-
proximately 27 years, with the vast majority
in the third and fourth decades of life. Ap-
proximately half of the angle fractures were
isolated mandibular fractures; the other half
having a contralateral fracture of the man-
dibular condyle, angle, body or symphysis.
All patients had arch-bars attached to the
dentition during surgery but none of the pa-
tients reported below were placed into post-
surgical intermaxillary fixation (IMF) unless
otherwise noted. However, the arch-bars were
left in place until the patient was fnnctionally
rehabilitated with an interincisal opening of
greater than 40 ram. This usually was from 4
to 8 weeks post-surgery. All other fractures
of the mandible (with the possible exception
of subcondylar) were treated with plate and/
or screw fixation, allowing immediate man-
dibular function. Even those patients who
had closed treatment of condylar fractures
were allowed immediate mobilization of the
mandible, but may have had elastics applied
to the dentition to "guide" them into proper
occlusion. The vast majority of fractures in
this patient population were sustained in
altercations/assaults (approximately 85
95%). The time between injury and presen-
tation for treatment ranged from a few hours
to several weeks, with an average of approxi-
mately 2.5 days. The average time between
injury and surgery was just over 3 days.
The data that were collected in each study
included: 1) age, 2) sex, 3) race, 4) number of
fractures per patient, 5) etiology, 6) associated
maxillofacial or other system trauma, 7) type
of fracture, i.e. comminuted versus linear, ob-
lique versus straight, 8) concomitant man-
dibular fractures, 9) presence of a tooth in the
line of fracture, 10) extraction of tooth in line
of fracture, 11) complications during surgery,
12) posts urgical occlusal relationship, and 13)
complications, which were defined as a need
for further surgical intervention. Only pa-
tients with a m i n i m u m follow-up of six weeks
were included. Approximately 80% of cases
had a tooth associated with the fracture in the
angle, and these were removed during surgery
in 60 80% of cases.
Closed reduction or intraoral open
reduction and non-rigid internal fixation
With the implementation of rigid forms of
internal fixation, closed reduction or non-ri-
gid internal fixation methods have become
less fashionable. However, when assessing
treatment results of new techniques, it is im-
portant to have a group for comparison. The
Treatment o f mandibular angle.fractures
Fig. 1. Immediate postoperative radiograph showing angle fracture treated with transosseous
wire fixation and intermaxillary fixation. Wire was inserted through the buccal cortex of the
extraction socket.
"gold standard" closed reduction or open
reduction using non-rigid fixation has been
used for centuries and constitutes such a
group. A retrospective study was performed
to gain an appreciation for the complication
rate of traditional treatment of angle frac-
tures in our patient population 49.
The records of patients treated by non-ri-
gid means of fixation for mandibular angle
fractures in a 3-year period were evaluated
retrospectively. Treatment of the fractures
was by closed reduction and/or open reduc-
tion with non-rigid means of interosseous
fixation such as transosseous wires, circum-
mandibular wires or small positional bone
plates (Fig. 1). Postsurgical I M F was pre-
scribed for six weeks in all patients.
During the 3-year period, 96 patients with
99 fractures through the mandibular angle
(three were bilateral) had charts available
with sufficient information for inclusion in
this studY. Of the 99 fractures, 59 were
treated with closed reduction (59%), 34 with
open reduction and placement of a transoss-
eous wire (34"/0), five with open reduction
and a positional bone plate, and one fracture
was treated by closed reduction with the ad-
dition of a circummandibular wire (1%). All
patients were placed into postsurgical I M F
for an average of 40 days (range 20 -80 days).
Follow-up ranged from 21 252 days with an
average of 75 days.
Complications developed in 17 fractures
(17%), of which there were 13 with infections
and four cases where infection was combined
with malunion and malocclusion. There were
no cases of non-union. The time between ini-
tial presentation and surgery in these patients
was similar to the overall group of patients.
All patients underwent incision and drainage
procedures for their infections. Nine patients
were hospitalized at least once for their infec-
tion and/or malocclusion/malunion. During
the incision and drainage procedures, four
patients underwent removal of osteosynth-
esis; two had teeth in the line of fracture ex-
tracted; three patients whose initial treatment
was closed reduction had transosseous wires
245
placed to control the proximal segment; one
patient required osteotomy to correct mal-
occlusion. Two patients required a second ad-
mission; one for incision and drainage, the
other for an osteotomy.
The results of this study showed that man-
dibular angle fractures in this patient popula-
tion were associated with a high incidence of
postsurgical complications, even when tra-
ditional methods of treatment were em-
ployed.
Extraoral open reduction and internal
fixation using the AO/ASIF reconstruction
plate
The AO reconstruction bone plate is a re-
inforced plate that is thicker and stronger
than the standard AO/ASIF compression
bone plate. It comes in various lengths and
the plate is three-dimensionally bendable,
allowing accurate contouring to the surface
of the mandible. The use of three screws on
each side of the fracture with this bone pIate
is claimed to provide adequate neutralization
of functional forces in the absence of coin-
pression 6~ it is useful in areas of commi-
nution, bone loss or obliquity where one can-
not use standard compression bone plates.
The records of all patients with unilateral
fractures of the mandibular angle treated
with a reconstruction bone plate over a 3-
year period were collected. The technique for
application of the plate has been published
elsewhere and consisted of an extraoral ap-
proach in most instances (Fig. 2) 21.
The records of fifty-two patients with uni-
lateral angle fractures treated in the 3-year
period, who had adequate follow-up infor-
mation in their chart, were available for re-
view. The fractures were categorized as being
comminuted in 31 cases, oblique in 12 and
simple linear fractures in 9. Following appli-
cation of the bone plate,' all fractures ap-
peared to be well reduced and stable. All
dentulous patients had a reproducible oc-
clusion in the operating room. Four patients
had pre-existent infections of the fracture
246 El/is

and irrigation drains were placed during
surgery in these patients. No other patient
had drainage of the wound. Postoperative
radiographs taken within the first two days
showed excellent reduction in aII cases. There
was no radiographic evidence of damage to
the inferior alveolar neurovascuIar structures
from placement of the fixation hardware. The
occlusal relationships were judged as normal
in all but four of the dentulous patients at
one week following surgery. These four pa-
tients had slight occlusal irregularities that
required two to three weeks of elastic traction
therapy. All four of these patients had con-
comitant fractures of the mandible in the
tooth-bearing area making it difficult to de-
termine which fracture(s) were not perfectly
reduced.
Follow-up ranged from 9 to 104 weeks
with a mean of 18 weeks. All dentulous pa-
tients had what was thought to be the nor-
mal occlusal relationship for that individual
at longest follow-up. Four fractures (7.5%)
required further surgical intervention for
postsurgical infections. These patients de-
veloped acute infections within the first three
postsurgical weeks that were refractory to
antimicrobial treatment. These patients re-
quired hospitalization for extraoral incision
and drainage, irrigation through drains, and
intravenous "antibiotics". One patient re-
quired plate removal to completely clear the
infection.
Lag screws for mandibular angle fractures
In 1981, NIEDERDELLMANNet al. 46 described
a method of internal fixation of mandibular
angle fractures using a single lag screw. We
began to use the lag screw technique in 1988
and found it to be an extremely rapid and
simple method for treating fractures of the
mandibular angle. The technique for placing
the lag screw has been described in previous
publications (Fig. 3) 19,25.
Eighty-eight patients that were treated by
open reduction and internal fixation of angle
fractures by the lag screw technique were in-
cluded in this study. Intraoperatively, reduc-
tions were judged as excellent in all patients.
However, 17 were noted to be unstable to ag-
gressive bimanual manipulation of the man-
dible. Supplemental methods of fixation were
applied in these cases. In three patients, a 2.0
mm compression bone plate was applied at
the inferior border. In the remaining 14 pa-
tients, postoperative I M F was used for vary-
ing periods (3-8 weeks). Follow-up ranged
from 6 to 167 weeks, with a mean of 22
weeks.
Immediate postoperative radiographic
evaluation showed excellent reduction in
every patient except one whose mandibular
ramus was slightly flared laterally on the sub-
mentovertex view. No treatment was necess-
ary, as the facial form was minimally altered.
Seven patients were found to have very minor
occlusaI discrepancies in the first two post-
operative weeks. These were treated satisfac-
tory with 3M weeks of intermaxillary elas-
tics. No other postsurgical malocclusion re-
sulted in any patient. One patient had
radiographic evidence of probable impale-
ment of the mandibular canal by the screw.
Eleven patients developed minor postsurgical
soft tissue infections/bone exposures within
the first several weeks (no cases of osteomyel-
itis occurred). Six resolved on oral anti-
microbial treatment without any further in-
tervention. Five patients (13%) required
further intervention, including removal of the
screws and small sequestra. One patient also
had extraction of a terminal molar that was
thought to be nonvital. Another patient de-
veloped non-union and was subsequently
bone-grafted.
Intraoral open reduction and internal
fixation using two 2.0 mm mini-dynamic
compression plates
One AO/ASIF method to neutralize the func-
tional forces of an angle fracture is by restor-

Fig. 2. Immediate postoperative radiograph showing infected angle Fig. 4. Immediate postoperative radiograph showing angle fracture
fracture treated with AO reconstruction bone plate. Plate was placed treated with two 2.0 mm dynamic compression plates.
through an extraoral approach. Penrose drain that was inserted dur-
ing surgery to help resolve infection can be seen. Drains were only
placed if fractures were infected.

Fig. 3. Immediate postoperative radiograph showing angle fracture Fig. 5. Immediate postoperative radiograph showing angle fracture
treated with solitary lag screw. treated with two AO/ASIF 2.4 mm compression plates designed for
use in mandible.

Fig. 6. Immediate postoperative radiograph showing angle fracture
treated with two non-compression miniplates.
ing the tension and compression trajectories
in the mandible 67. The recommended method
to restore these trajectories in fractures of the
mandibular angle is by the application of two
bone plates; one at the superior and one at
the inferior border of the buccal cortex. Tra-
ditionally, the plate at the superior border
was a small compression plate secured with
monocortical screws, whereas the one at the
inferior border was a large compression
plate, using bicortical screws. The appli-
cation of these two bone plates is not difficult
through an extraoral approach. However,
placement of these plates via an intraoral ap-
proach is more demanding due to decreased
visibility, making adaptation of the bone
plates difficult. Because of the difficulties en-
countered in adapting and securing the larger
bone plates, the implementation of two 2.0
mm mini-dynamic compression plates was
undertaken in a sample of patients (Fig. 4) 2~
Thirty consecutive patients with 31 frac-
tures of the mandibular angle that were
amenable to compression plate osteosynth-
esis were treated by open reduction and inter-
nal fixation using two mini-dynamic com-
pression plates placed through a transoral in-
cision with transbuccal trocar instru-
mentation. Nine fractures (29%) experienced
complications requiring secondary surgical
intervention. Three were early infections re-
quiring incision and drainage, removal of the
plates and postoperative IME One was a
non-union with malocclusion requiring ap-
plication of a more rigid bone plate. Five
fractures developed late chronic swelling and
low-grade infection requiring plate removal.
Osseous union had occurred in these cases
and no postoperative IMF was necessary.
Intraoral open reduction and internal
fixation using two 2.4 mm mandibular
dynamic compression plates
Because of the high rate of postsurgical com-
plications in patients treated with two 2.0
mm mini-dynamic compression plates, it was
decided to study the standard AO/ASIF tech-
nique for treating fractures of the mandibu-
lar angle by the application of two com-
Treatment o f mandibular angle fractures
Fig. 7. Immediate postoperative radiograph showing angle fracture
treated with single non-compression miniplate according to the prin-
ciples of CHAMPY et al) 2.
pression bone plates specifically designed for
the mandible. The tension band dynamic
compression plate employed 2.4 mm screws
that were applied monocortically in locations
where bicortical engagement would damage
normal anatomic structures, such as over
tooth roots. The stabilization plate was a
larger compression bone plate using 2.4 mm
bone screws. Additionally, postsurgical suc-
tion drainage was used in all cases.
Sixty-five consecutive patients with 65
fractures of the mandibular angle were
treated by open reduction and internal fix-
ation using two dynamic compression plates
placed through a transoral incision with
transbuccal trocar instrumentation and 2.4
mm screws (Fig. 5) 22. Overall, 21 fractures
(32%) experienced infections requiring sec-
ondary surgical intervention. Of the 21 frac-
tures which required plate removal, nine frac-
tures were healed and required no further
treatment; 12 had no firm bony union and
required postsurgical IME Only one case re-
sulted in a malunion with resulting malocclu-
sion.
Intraoral open reduction and internal
fixation using two noncompression
miniplates
The AO/ASIF recommendation for appli-
cation of two compression bone plates for
angle fractures was found to result in very
high rates of complication in our patient
population 2~ Because large bony se-
questra were frequently encountered in these
patients, we thought that a reason for the
high rate of postoperative infection was devi-
Table 1. Comparison of 2.0 mm and 1.3 mm miniplates*
Thickness (mm)
In-plane stiffness (N-m 2)
Out-of-plane stiffness (N-m 2)
In-plane bending strength (N-m 2)
Out-of-plane bending strength (N-m 2)
* Provided by Synthes USA, Paoli, PA,USA
247
talization of bone resulting from the use of
compression plates. The hypothesis was put
forward that eliminating the use of com-
pression might improve treatment results.
The next series of patients with fractures of
the mandibular angle were, therefore, treated
with two 2.0 mm non-compression mini-
plates (Fig. 6). The superior bone plate was
applied monocortically, the inferior bone
plate bicortically. The technique for appli-
cation of the two bone plates has been pub-
lished elsewhere23.
Sixty-seven consecutive patients with 69
fractures of the mandibular angle were
treated by open reduction and internal fix-
ation using two non-compression miniplates
placed through a transoral incision with
transbuccal trocar instrumentation and 2.0
mm self-threading screws. Overall, 19 frac-
tures (28%) experienced complications re-
quiring secondary surgical intervention.
Most of the complications were postopera-
tive infections requiring surgical drainage
(n=lT) and subsequent plate removal (rl=
16). Of the 17 infected fractures, 11 were
healed at the time of plate removal and re-
quired no further treatment. Five were still
mobile and required a period of I M F for
healing. One of the fractures did not heal and
required bone grafting.
Intraoral open reduction and internal
fixation using one non-compression
miniplate
Because of the high rates of complication re-
sulting when two bone plates were placed, it
was decided to attempt the use of a single
2.0 mm plate 1.3 mm plate
0.9 0.5
0.007 0.001
0.158 0.029
0.14 0.04
0.93 0.40
248 Ellis
miniplate according to the principles of
CHAMPu et al. 12 (Fig. 7). Eighty-one consecu-
tive dentate patients with non-comminuted
fractures of the mandibular angle were
treated by intraoral open reduction and
internal fixation using a single four-hole
miniplate and monocortical screws in a two-
year period23i Following application of the
bone plate, all fractures appeared to be well
reduced and stable. Postoperative radio-
graphs taken within the first two days showed
excellent reduction in all cases except four,
where a 2~4 m m gap was noted at the in-
ferior border. In spite of this finding on
radiographs, immediate occlusal relation-
ships were judged as normal in all but one of
these patients, who had an slight posterior
open bite on the side of the fracture, and re-
sponded to light elastic traction for 10 days.
Besides this case, two other patients had
slight malocclusions that responded to the
wearing of elastics for one or two weeks. At
the time of arch-bar removal, occlusal re-
lationships were judged as n o r m a l in all
cases.
Overall, 13 angle fractures (16%) experi-
enced complications requiring secondary sur-
gical intervention. Most of the complications
( n = l l ) , however, were minor and could be
treated in the outpatient setting. Most com-
monly, intraoral incision and drainage and
later removal of the bone plate were required.
Fig. 9. Immediate postoperative radiograph showing angle fracture treated with single 1.3 m m
non-compression plate.
Fig. 8. Photograph of standard 2.0 m m miniplate and 1.3 m m mini-
plate used in this investigation (A). 1.3 m m plate is extremely thin
and malleable as shown in this photograph (B).
All patients with minor complications had
bony union. Only two complications re-
quired hospitalization for intravenous anti-
microbial treatment and further surgery. One
of these patients had a fibrous union, requir-
ing a bone graft.
Intraoral open reduction and internal
fixation using one malleable non-
compression miniplate
The use of a single miniplate for fractures of
the angle of the mandible was a simple, re-
liable technique with a relatively small num-
ber of major complications. However, the
question "how m u c h fixation is adequate?"
was still not known. LoDD~ 13 has reduced the
volume of the original CHAMPY miniplate by
half, making them much more malleable, and
has not noted any increase in complications
when used for mandibular fractures. How
much reduction in material is tolerable? The
purpose of this last investigation was to pro-
spectively evaluate the use of a thin, malle-
able miniplate (Synthes Maxillofacial, Paoli,
PA, USA) that employs 1.3 m m screws for
stabilization of fractures of the mandibular
angle. This plate was not designed for use in
the mandible, but was designed for use in the
non-load bearing regions of the midface
(Table 1)(Fig. 8). Patients had a seven-hole
strip of the plate secured across the fracture
using three monocortical strews on each side
of the fracture. Because of the thinness and
malleability of the plates, it was unnecessary
to bend the bone plates, allowing the screws
to simply coapt the plates to the bone upon
tightening. No transbuccal trocar was necess-
ary for instrumentation. All screws were 5
m m in length.
Forty-six consecutive patients with 51
fractures of the angle of the mandible were
treated by the above method (five were bilat-
eral) in a 1.5-year period (Fig. 9) St. Following
application of the bone plate, all fractures
appeared to be well reduced and stable. Post-
operative radiographs taken within the first
two days showed excellent reduction in all
cases. Immediate occlusal relationships were
judged as normal in all but one patient,
whose mandible was shifted to the contra-
lateral side in association with moderate
swelling of the right submandibular and lat-
eral pharyngeal spaces due to infection of
these spaces present prior to surgery. This re-
solved with the resolution of infection and
the use of light elastics for 14 days. At the
time of arch-bar removal, one patient was
judged to have a malocclusion that was attri-
buted to malunion at a fracture site other
than the angle. All other occlusal relation-
ships were judged normal.
Seven patients (13.7%) developed compli-
cations from their angle fracture postopera-
tively, only four (8.7%) required further sur-
gical intervention. All complications were
considered minor and consisted of plate frac-
ture, local infection, or both. Three of the
seven patients (42.9%) had asymptomatic
fracture of the plate diagnosed on radio-
graphs, however there was bony union of the
fracture and no intervention was required.
Two patients (28.6%) had fracture of the
plate with clinical mobility of the fracture
and were placed into I M F for a period of
6 weeks. One of these patients subsequently
developed a localized infection of a devital-
ized tooth in the line of fracture and was
treated with oral antimicrobial drugs and ex-
traction of the offending tooth. One patient
(14.3%) developed an isolated infection as-
sociated with a nonvital tooth that was

Table 2. Treatment for angle fractures (Parkland Memorial Hospital)
Treatment
Non-rigid fixation
AO reconstruction plate (2.7 mm)
Solitary lag screw
Two mini-dynamic compression plates (2.0 mm)
Two mandibular dynamic compression plates (2.4 ram)
Two non-compression miniplates (2.0 mm)
One non-compression miniplate (2.0 ram)
One malleable non-compr miniplate (1.3 mm)
~ Major complication refers to the necessity of hospitalization to treat complication
treated by intraoral incision and drainage,
extraction of the tooth, and oral "anti-
biotics" without plate removal. One patient
(14.3%) developed an isolated infection as-
sociated with loosening of the. plates several
weeks after completing rehabilitation, and
was treated with oral "antibiotics" and re-
moval of the plate under local anesthesia. No
patient developed major complications that
required hospitalization or intravenous anti-
microbial therapy.
Discussion
In our patient population, treatment of
angle fractures with even traditional
methods closed reduction and/or non-
rigid fixation produced a high rate of
complication (17%) 49. This might sur-
prise those surgeons from countries
where fractures occur in a higher socio-
economic group of patients. However,
the association of poor oral hygiene,
poor dentition, substance abuse and a
variety of other factors may predispose
this particular sample of patients to
postsurgical complications48.
The most useful techniques in this
patient population were the use of
either an extraoral open reduction and
internal fixation with the AO/ASIF re-
construction plate, or intraoral open re-
duction and internal fixation using a
single miniplate (Table 2). The use of
the reconstruction bone plate was
found to result in few complications in
a study of angle fractures by IIZUKA&
LINDQVIST35. However, the application
of this plate is much easier through an
extraoral approach that can create its
own set of complications. Obviously, we
currently employ the latter approach
with a 2.0 mm plating system for the
vast majority of cases. Every attempt
we made at using a two-plate technique
via a transoral approach was fraught
with high rates of sequestra formation,
infection and need for subsequent
surgery. We no longer recommend an
intraoral two-plate technique.
Treatment of mandibular angle.fi'actures
Study Reference Sample (no. of angles)
PASSE•I et al., 199349
ELLIS, 199321
ELLIS & GHALI,199119
ELLIS & KARAS,19922o
ELLIS& SINN, 199322
E>LIS & WALrCER,199423
ELLIS& WALKER,199624
POTTER& ELLIS, 199951
At the beginning of these investi-
gations, we never would have con-
sidered using a single miniplate to ad-
equately stabilize a fracture of the angle
of the mandible without supplemental
IME Ten years ago, indoctrinated by
the AO/ASIF teaching that absolute ri-
gid fixation was necessary, stable
methods were deemed necessary and
were used in this patient population.
Reconstruction plates, lag screws, and
two-plate systems were implemented
with the thought that they were absol-
utely stable methods. However, other
than the reconstruction plate, the intra-
oral techniques of stable fixation proved
either unstable in a certain percentage
of cases (solitary lag screw) or fraught
with high rates of major postsurgical
complications (two plates).
The results of these consecutive
series of clinical investigations per-
formed in our hospital on a similar pa-
tient population indicate that, contrary
to popular beliefs, up to a point, the in-
cidence of major complications after
fractures of the mandibular angle are
inversely proportional to the rigidity of
the fixation applied. Whenever two
points of fixation were used for frac-
tures of the angle, the complication rate
was much higher than when one point
of fixation was applied. That is not to
say that using a single miniplate does
not result in complications. However,
the vast majority of problems that arose
in patients treated by a single miniplate,
such as wound dehiscence, wound infec-
tions, plate exposure etc., were easily
treated in the outpatient clinic under lo-
cal anesthesia. Even removal of the
bone plate after healing of the fracture,
when necessary, is a simple procedure in
the outpatient setting. However, when a
second plate was applied at the inferior
border, the complications tended to be
more severe, with large areas of nonvital
bone, sequestra formation and need for
plate removal, which were difficult to
249
Major Complication~
99 17%
52 7.5%
88 13%
30 13%
65 32%
67 23%
81 2.5%
51 0%
treat in the outpatient setting. If one de-
fines a complication as an unplanned
intervention, the two-plate techniques
have a higher complication rate than
single plate techniques. However, when
one defines a major complication as one
that requires hospitalization to treat the
problem, the difference between treat-
ment techniques becomes much more
clear and dramatic in incidence (see
Table 2).
The finding that a single minipiate
outperforms two plates and other more
stable forms of fixation defies logic, be-
cause conventional wisdom would indi-
cate that more stable fixation should
provide fewer complications. However,
our experience has been the opposite.
The use of a single miniplate was as-
sociated with much fewer complications
than if two plates were used, irrespective
of whether the two plates were com-
pression or non-compression plates.
This seeming dichotomy highlights the
limitations of relying on the results of
biomechanical bench testing for clinical
treatment recommendations. All bio-
mechanical tests performed to date in-
dicate that two plates are more stable
than one 14,15,18,2a'38,57,58,62. Based upon
these biomechanical studies and clinical
results, some investigators have advo-
cated the use of two miniplates for frac-
tures of the mandibular angle 14,15,41,71
LEvY et al. 41 compared a small sample
of patients who had fractures of the
angle treated with either one or two
miniplates without postsurgical IME
There were no complications in the 18
patients who had double miniplates,
but two complications in the ten pa-
tients (20%) who had a single miniplate.
Interestingly, another sample of 14 pa-
tients with two miniplates plus postsur-
gical I M F had a greater rate of compli-
cation (7.1%) than when no IMF was
used.
Our clinical experience is exactly the
opposite - a single miniplate worked
250 Ellis
much better than double plating sys-
tems. SHIERLE et al. 58 compared a single
miniplate to the use of two and found
no significant difference in results. The
results of our studies and the one by
SCHIRLE et al. 58 indicate that bio-
mechanics are only one factor to be
considered when treating fractures.
There are many others that may be
more important. Perhaps improved
maintenance of the blood supply to the
bone because of limited dissection is
one such factor s 7,17,32. We, therefore,
agree with EWERS & HARLE 26'27 who
questioned the need for absolute rigid-
ity for treatment of fractures. F r o m the
foregoing, it is obvious that fractures of
the mandibular angle do not require the
amount of stability as determined in
biomechanical tests. This should not be
surprising in light of bite force studies
by GERLACH et al. 3~ and TATE et al. 69
which showed that bite forces are sub-
normal for many weeks after fracture of
the mandible.
W h a t has yet to be determined is
exactly what are the requirements for
fixation of angle fractures. Based upon
the results of using a malleable 1.3 m m
plating system, this plate should not be
routinely used for such fractures be-
cause some fractured during function.
However, the fact that most did not
fracture indicates that the 2.0 m m mini-
plates are probably over-engineered for
this task. Perhaps a thinned down ver-
sion of the 2.0 mm miniplate system
will prove even simpler to apply and ad-
equately stable without plate fracture.
Another alternative might be to thicken
the 1.3 m m plate. These results also in-
dicate that biodegradable fixation sys-
tems, which do not have the same
strength as metallic plates of the same
dimension, may provide adequate fix-
ation in this region.
There have been studies on the treat-
ment of fractures of the mandible that
have shown that operator experience is
an important factor in treatment re-
sults 3'34'37. There is no question that ex-
perienced surgeons can treat injuries
faster and perhaps with less surgical
trauma that those who are less experi-
enced. Because the techniques that
proved most beneficial were those com-
pleted latest in this 10-year experience,
one might argue that the improved re-
sults are not due to treatment methods
but instead due to operator experience,
which one would presume to increase
over time. There is one factor that re-
futes this supposition, however. A var-
iety of residents were involved with the
operative procedures over the 10-year
pcriod. The experience level of the resi-
dents was similar because they rotated
to the treating hospital for the same
duration during their training pro-
grams. The only individual present over
the entire 10 years was the faculty sur-
geon, who merely directed and assisted
during the surgery. At least one other
study has also demonstrated that single
plates perform as well as when two are
used 58.
A more important consideration
about operator experience, however, is
that it takes much less experience to be-
come adept at using a single miniplate
than the other techniques. Application
of a single miniplate takes only a few
minutes and can be taught very quickly
to a trainee. Placement of the second
plate at the inferior border is a more
difficult task and requires more experi-
ence to become facile. Placement of a
solitary lag screw is also technique sen-
sitive. Fortunately, the technique that
offers the best results is also that which
is the simplest to learn.
The use of a single miniplate was not
in keeping with the original A O / A S I F
principles. Historically, the four AO/
A S I F principles for treating skeletal
fractures were: 1) anatomic reduction;
2) rigid fixation; 3) atraumatic surgical
technique; and 4) immediate active
function, in 1994, the A O / A S I E for the
first time in its history, changed the sec-
ond principle to "functionally stable
fixation", rather than rigid fixation.
This change arose out of orthopedic
surgery, where intramedullary nails and
other less "rigid" forms of fixation were
proven to be "functionally" stable. The
ability of a single miniplate applied at
the superior border of the mandible to
"neutralize" functional forces and allow
immediate active mobility is finally rec-
ognized by the A O / A S I F as a reliable
means of providing functional stability
of the fracture.
The above relates the experience of
one hospital, with one patient popula-
tion, treated by a large group of resi-
dents with one faculty member.
Whether or not the results are repeat-
able at other institutions is unknown.
Scientifically, the question about which
technique offers the best result will
require a randomized prospective
study. This type of a study will allow
factors such as operator experience,
patient population and the multitude
of other uncontrolled factors to be less
likely to affect the outcome. Such a
study has not yet been performed but
is currently underway in the United
States.
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Address:
Edward Ellis 11I, D.D.S., M.S.
Professor, Oral and Maxillofacial Surgery
The University of Texas Southwestern
Medical Center
5323 Harry Hines Blvd. CS3.104
Dallas, Texas 75235 9109
USA
Tel." +1 214 648 8963
Fax: +1 214 648 7620
e-mail: eellis@mednet.swmed.edu