J Oral Maxillofac Surg 66:2116-2122, 2008

Is the Use of Arch Bars or Interdental Wire Fixation Necessary for Successful Outcomes in the Open Reduction and Internal Fixation of Mandibular Angle Fractures?
R. Bryan Bell, DDS, MD,* and David M. Wilson, BA
Purpose: The purpose of this retrospective cohort study was to analyze the complications associated

with a series of mandibular angle fractures treated by open reduction and internal xation and to determine if the method of intraoperative maxillomandibular xation (MMF) affected patient outcome.
Patients and Methods: The records of 162 consecutive patients with isolated mandibular fractures that were treated by the senior author (R.B.B.) with open reduction and internal xation were retrospectively reviewed and a number of clinical variables were recorded. Of these, all patients with fractures involving the mandibular angle, alone or in combination with other mandibular fractures, were identied. Only patients in the permanent dentition with angle fractures treated with a single 2.0 mm titanium plate placed at the superior border using standard Champy technique were included in the study. Patients with less than 6 weeks follow-up, concomitant midface fractures, edentulous patients, patients with comminuted fractures or gunshot wounds, and those patients presenting with infected fractures were excluded from the primary study group, which totaled 75 patients with 83 angle fractures. Postoperative complications, including infection, malunion/nonunion, wound dehiscence, osteomyelitis, pain, and the need for secondary operative intervention, were tabulated. For purposes of comparison, patients were divided into 3 groups based upon the type of intraoperative MMF utilized: group 1, Erich arch bars (n 24); group 2, 24 gauge interdental Stout wires (n 25); and group 3, manual reduction alone (n 26). Outcome measures were dened as successful bone healing, acceptable occlusion, minor complications, and major complications. Descriptive statistics were recorded and an analysis of variance was calculated to evaluate differences between the 3 groups. The Fishers exact test was used to evaluate whether a complication occurred more frequently in any one particular group.

63, F 12) and there were no signicant demographic differences between the 3 groups (P 0.22). All patients eventually achieved successful bony union with an acceptable occlusion. Thirty-two percent of patients in the cohort required a second procedure, usually outpatient removal of loose or symptomatic hardware under local anesthesia or intravenous sedation, but there was no difference in re-operation rate based upon the method of intraoperative xation (P .47). Major complications occurred in 2 patients that required secondary operations due to malunion and nonunion (2.7%). Twenty-two minor complications occurred in 16 patients (21.3%) and were evenly distributed amongst the 3 groups (P .074), including infection (n 4), wound dehiscence (n 1), and/or symptomatic hardware (n 16) that required hardware removal. All of the minor complications were treated in an outpatient setting under local anesthesia or under intravenous sedation. When the complications were pooled together, the Fisher exact test again yielded no difference in complications between the 3 groups (P .33).
*Attending Surgeon and Director of Resident Education, Oral and Maxillofacial Surgery Service, Legacy Emanuel Hospital and Health Center; and Clinical Associate Professor of Oral and Maxillofacial Surgery, Oregon Health and Science University, Portland, OR. Formerly, Dental Student, Oregon Health and Science University, School of Dentistry, Portland, OR; and Currently, Resident, Department of Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, MI. Address correspondence and reprint requests to Dr Bell: Legacy Emanuel Hospital and Health Center, Oral and Maxillofacial Surgery Service, 1849 NW Kearney, Suite 300, Portland, OR 97209; e-mail: bellb@hnsa1.com
2008 American Association of Oral and Maxillofacial Surgeons

Results: The mean age of the 75 patients included in the study was 28.2 years (M

0278-2391/08/6610-0021$34.00/0 doi:10.1016/j.joms.2008.05.370

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Conclusion: The use of Erich arch bars or interdental wire xation to assist with MMF during the open reduction and internal xation of noncomminuted mandibular angle fractures treated in Champy fashion is not always necessary for successful outcome. 2008 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 66:2116-2122, 2008

Fractures involving the mandibular angle are treated with a variety of techniques.1 Functionally stable osteosynthesis whereby a single noncompression miniplate is placed along the superior border of the external oblique ridge has gained widespread acceptance (Fig 1). Described by Michelet et al2 and validated by Champy et al,3 3 decades of experience have shown that this method results in predictable clinical outcomes without the use of postoperative maxillomandibular xation (MMF), and that it meets the biomechanical principles set by the Association for the Study of Internal Fixation (AO/ASIF).4 The advantages to using the Champy method include a decreased risk of infection, shorter operating time, and more rapid return to form and function when compared with other more rigid techniques. The use of interdental wire ligatures or arch bars for intraoperative MMF has been a time-honored and reliable technique to aid in the reduction and stabilization of mandibular fractures before the application of plate xation. The problem with this technique, however, is that it is time consuming and there is a signicant risk of skin puncture, possibly resulting in disease transmission to the surgeon. Some authors have attempted to minimize these risks and improve operating room efciency by omitting wire/arch bar MMF altogether, in favor of manual reduction of the fractures alone (Fig 2).5,6 Although this approach does not seem to have gained much traction amongst North American oral and maxillofacial surgeons, there is recent evidence to suggest that many experienced surgeons from other countries and other surgical specialties do not, in fact, routinely use arch bars or interdental wire xation to aid in the reduction, stabilization, and xation of mandibular fractures.7 The authors approach to mandibular angle fractures has evolved over the last 5 years to the point of avoiding the placement of arch bars to assist in intraoperative MMF whenever possible (Fig 3). Although interdental wire xation continues to play an important role in the management of mandibular fractures, few studies have evaluated the efcacy of manual reduction alone for achieving adequate stabilization to apply internal xation. The goal of the current study was to test the hypothesis that intraoperative MMF using interdental wire xation is not always necessary for successful open reduction and internal xation of mandibular angle fractures. To this end, the authors carried out a retrospective cohort study to

analyze the management of a series of patients with mandibular angle fractures treated by open reduction and internal xation using the Champy technique, assess the complications, and determine if the method of intraoperative MMF affected patient outcome.

Patients and Methods

The records of 162 consecutive patients with mandibular fractures that were treated at Legacy Emanuel Hospital (Portland, OR) by a single attending surgeon (R.B.B.) and one of several resident surgeons with open reduction and internal xation were retrospectively reviewed. Of these, all patients with fractures involving the mandibular angle, alone or in combination with other facial fractures, were identied. Only patients in the permanent dentition with angle fractures treated with a single 2.0-mm titanium plate placed at the superior border via a transoral approach using standard Champy technique were included in the study. Patients with less than 6 weeks follow-up, those with inadequate preoperative or postoperative imaging, concomitant midface fractures, edentulous patients, patients with comminuted fractures or gunshot wounds, and those patients presenting with infected fracture were excluded from the study. Demographic and treatment data were recorded on an Excel spreadsheet (Microsoft, Seattle, WA) including: gender, age, ethnic origin, medical comorbidities, smoking, mechanism of injury, type and location of mandibular fracture, teeth in the line of fracture, antibiotics, delay to surgery, and concomitant injuries. Postoperative complications were similarly tabulated, including: infection, loose/symptomatic hardware, wound dehiscence, osteomyelitis, malunion/ nonunion, and the need for secondary operative intervention. Patients were divided into 3 comparative groups based on the type of intraoperative MMF used: group 1, Erich arch bars (n 24); group 2, 24-gauge interdental Stout wires (n 25); and group 3, manual reduction alone (n 26). Outcome measures were dened as successful bone healing, acceptable occlusion, minor complications, and major complications. Major complications were those that required a return trip to the operating room for a second procedure to be carried out under general anesthesia. A minor complication was one that could be managed in the

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FIGURE 1. Illustration of Champys technique for repair of mandibular angle fractures. Bell and Wilson. Intraoperative MMF Techniques. J Oral Maxillofac Surg 2008.

ofce on an outpatient basis. Descriptive statistics were recorded and an analysis of variance was calculated to evaluate differences between the 3 groups. The Fishers exact test was used to evaluate whether a complication occurred more frequently in any one particular group.

cluded in group 2. Twenty-six patients had fractures manually reduced at the time of ORIF without the aid of interdental wire xation. An analysis of variance was unable to distinguish signicant demographic differences between the 3 groups, indicating that they are comparable (P .22). All patients eventually achieved successful bony union with an acceptable occlusion. Thirty-two percent of patients in the cohort required a second procedure, usually outpatient removal of loose or symptomatic hardware under local anesthesia or intravenous sedation (IV) (Table 2). When the Fisher exact test was applied to the data in Table 2, there was no difference in re-operation rate based on the method of intraoperative xation (P .47) Major complications occurred in 2 patients in group 2 that required secondary inpatient operations under general anesthesia due to malunion and nonunion (2.7%). Twenty-two minor complications occurred in 16 patients (21.3%), including infection (n 4), wound dehiscence (n 1), or loose/symptomatic hardware (n 16). All of the minor complications were treated in an outpatient setting under local anesthesia or under IV sedation. The Fisher exact test was applied to the complication data in Table 3 and was unable to distinguish a difference in individual complications based on the type of MMF (P .074). When the

Results
Seventy-ve patients with 83 angle fractures met the criteria for inclusion in the study, the demographics of which were typical of urban trauma patients, and are listed in Table 1. The mean age of the study cohort was 28.2 years and consisted of more men than women (M 63, F 12). Medical comorbidities were present in 35% of the cohort and generally consisted of diabetes mellitus, asthma, or hypertension. Fifty-three percent of the patients in the study regularly smoked cigarettes. The majority of patients were injured as a result of interpersonal violence, in addition to motor vehicle accidents, falls, sporting injuries, and other etiologies. Sixty-one percent of patients presented with fractures of the mandibular body, symphysis or condyle, in addition to at least one angle fracture. Eighty percent of the cohort had teeth in the line of the angle fracture. All mandibular angle fractures in the study were treated with open reduction and internal xation (ORIF) using a 2.0-mm titanium plate and screws placed along the superior border via a transoral approach as described by Champy et al3 and Michelet et al.2 Twenty-four patients had arch bars placed at the time of ORIF and were included in group 1. Twentyve patients received Stout wires and were in-

FIGURE 2. Clinical photograph demonstrating the technique of manual reduction and stabilization prior to the application of rigid internal xation. Bell and Wilson. Intraoperative MMF Techniques. J Oral Maxillofac Surg 2008.

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FIGURE 3. A 16-year-old female involved in a soccer accident during which she sustained displaced fractures of the left mandibular angle and right parasymphysis. A, Preoperative occlusion. B, Preoperative panoramic radiograph. C, Intraoperative photograph showing repair of left angle fracture (Champy technique). D, Repair of the left parasymphysis fracture. E, Intraoperative occlusion after reduction, stabilization, and xation. F, Six weeks postoperative panoramic radiograph. G, Three months postoperative occlusion. Bell and Wilson. Intraoperative MMF Techniques. J Oral Maxillofac Surg 2008.

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Table 1. VARIABLES

Variables Male/female Mean age (range) Medical comorbidity Smoking Ethnicity Caucasian African American Asian Hispanic Native American Mechanism of fracture Assault Motor vehicle accident (MVA) Fall Sports Extractions Miscellaneous Concomitant mandibular fractures Percentage treated with concomitant fractures (%) Outcome of teeth in fracture line Teeth along fracture line Teeth extracted along fracture line Impacted teeth along fracture line Antibiotics Delay to surgery *Erich arch bars. Interdental wires. Manual reduction.

Group 1* (n 21/3 21.0 (13-47) 7 8 19 3 0 1 1 12 5 1 5 0 1 20 83.3 18 4 14 23 12

24)

Group 2 (n 20/5 24.8 (16-38) 7 14 20 4 0 1 0 19 2 2 1 0 1 11 44.0 22 8 17 23 11

25)

Group 3 (n 24/2 26.0 (17-61) 12 18 20 5 0 1 0 17 2 3 1 3 0 15 57.7 20 11 12 26 15

26)

Bell and Wilson. Intraoperative MMF Techniques. J Oral Maxillofac Surg 2008.

complications were pooled together, again the Fisher exact test yielded no difference in complications between the 3 groups (P .33).

Discussion
The application of Erich arch bars to the maxillary and mandibular dental arches remains the gold standard for re-establishing a stable occlusion before the open reduction and internal xation of facial fractures in general, and mandibular fractures in particular. However, the risk of glove puncture, inadvertent wire stick and resultant disease transmission, lack of oper-

ator experience, and time constraints make the routine use of Erich arch bars impractical or unattractive for many clinicians.8 Additionally, several authors have suggested that interdental wiring may have an adverse effect on the teeth and surrounding tissues.9,10 Our experience suggests that Erich arch bars, interdental Stout wires, and manual reduction alone all have efcacy for achieving favorable bony union in the open reduction and internal xation of mandibu-

Table 3. PATIENT OUTCOME

Outcome
Table 2. RE-OPERATION

Group 1* (n 24) 18 2 0 5 1 0

Group 2 (n 25) 18 1 2 5 0 0

Group 3 (n 26) 16 1 0 6 0 1

Re-Operation Yes No

Group 1* (n 24) 6 18

Group 2 (n 25) 8 17

Group 3 (n 26) 10 16

Normal result Infection Malunion/nonunion Loose/symptomatic hardware Wound dehiscence Osteomyelitis *Erich arch bars. Interdental wires. Manual reduction.

*Erich arch bars. Interdental wires. Manual reduction.

Bell and Wilson. Intraoperative MMF Techniques. J Oral Maxillofac Surg 2008.

Bell and Wilson. Intraoperative MMF Techniques. J Oral Maxillofac Surg 2008.

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2121 border plate placed via a transbuccal trocar, to that described by Champy of a single superior border plate placed transorally. All patients with mandibular fractures combined with midfacial fractures, as well as the majority of patients with isolated mandibular fractures, are managed with Erich arch bars or interdental wire xation to aid in intraoperative MMF. One of the advantages of this approach is that the occlusion may be controlled postoperatively. Early xation failures or minor alterations in occlusion can potentially be managed with intermaxillary elastic bands or wire MMF. Important disadvantages, as noted above, are that the interdental wires place the surgeon at risk of skin puncture and they are uncomfortable to the patient during the postoperative period. Our results suggest that interdental wires can be avoided in selected patients, thus reducing disease transmission and improving patient comfort during healing. Patients are typically selected on the basis of the fracture displacement, fracture pattern, and the perceived ability of the patient to comply with postoperative functional restrictions during healing. The complication rate of 32% in the current study is deceptively high because virtually all patients had a favorable outcome with successful bony union and return to premorbid occlusion. It should be noted that all but 2 patients had their complications managed on an outpatient basis, under local anesthesia or IV sedation, and almost always after bony union had been achieved. The majority of the complications consisted of hardware removal, which is a limitation inherent in the Champy technique itself, and less related to the method of intraoperative MMF used.17,18 The severity of complications and the incidence of hardware removal in the current study is similar to previous publications using the Champy technique. Ellis and Walker19 reviewed 81 patients treated in similar fashion and noted favorable results. Thirteen patients with angle fractures (16%) experienced complications requiring secondary surgical intervention. However, most of the complications (n 11) were minor and could be treated in the ofce. Most commonly, intraoral incision and drainage and later removal of the bone plate were required. All patients with minor complications had clinical union. Only 2 complications required hospitalization for IV antibiotics and further surgery. One of these patients had a brous union requiring a bone graft. As noted above, the ndings in this investigation, that there is no difference in outcome between the 3 treatment methods studied, is not the same as saying that the 3 techniques are equivalent. There are significant limitations to the current study related to uncertainty associated with the statistical comparisons. For example, if we conne out attention to a comparison

lar angle fractures using the Champy technique. Furthermore, the use of Erich arch bars or interdental wire xation to assist with MMF during surgery is not always necessary for successful outcome. The conclusion that we cannot statistically distinguish between the methods of intraoperative MMF should not be taken to mean that the treatments are equivalent. There is no question that Erich arch bars are preferable for the treatment of comminuted fractures and those mandibular fractures with concomitant midfacial fractures. However, there are many isolated mandibular fractures that are minimally displaced or favorably displaced for which the application of arch bars, with their associated risk of skin puncture and added operative time, may not be warranted. In these cases, the use of interdental wire xation or manual reduction alone may be considered. An important contraindication for manual reduction of mandibular fractures (no interdental wire xation) is when there is just 1 operating surgeon and no experienced assistant available during the procedure. In this instance, the use of some type of intraoperative MMF (either arch bars of interdental wires) is helpful for stabilizing the occlusion before the application of rigid xation. The ideal number of assistants required to accurately reduce and stabilize the fractures without intraoperative MMF is 2: the rst assistant, to provide suction and retraction; and the second assistant to maintain a stable occlusion and favorable reduction of the fractured segments. Although patient noncompliance is a potential contraindication for avoiding interdental wires, this may be as much of a limitation of the Champy technique itself, rather than the lack of intraoperative/postoperative MMF. Recently, a number of authors have advocated for the use of intermaxillary xation (IMF) screws to aid in intraoperative MMF.11-14 Although these screws do seem to have efcacy, inadvertent injury to the surrounding dentition is a signicant risk, and they have limited use in partially edentulous patients.15 Coletti et al16 recently published a retrospective study on 49 facial fracture patients who were treated with IMF screws and noted at least 1 adverse event in 39% of the patients, the most common of which was screw loosening (29%). Other complications were noted including root fracture, loosened wires, screw shear, malocclusion, and ingested hardware. Additional studies are needed to further dene the indications and contraindications for the use of IMF screws in mandibular fracture treatment. The authors approach to most mandibular angle fractures during the last 7 years has evolved from one that applied AO/ASIF principles of compression plating to the inferior border combined with a superior

2122 between Erich arch bars and manual MMF alone using the Fisher exact test we nd an odds ratio of 1.75 indicating that the frequency of re-operation is 1.75 greater for the manual group than for the Erich. Additionally, with a 95% condence region of 0.61 to 5 we cannot be sure if the manual procedure is not better than the Erich, and we cannot be sure it may not be 5 times worse. These inconclusive results are typical of underpowered studies: the study does not have enough cases. If the true difference in the reoperation rate is the same as the data states, and we conne ourselves to the 2 groups, Erich and Manual, then the study would require about 300 patients in each group to have a study with 82% power. If such a study was conducted, and the 2 treatments had identical re-operation rates, the 95% condence region on the odds ratio would be from 0.7 to 1.4. The 95% condence region on the difference in fraction re-operated would be 0.08 to 0.08. Acknowledging these limitations, we may still conclude that the use of intraoperative interdental wire xation (arch bars or Stout wires) as an aid to the open reduction, stabilization, and xation is not always necessary for successful outcomes in selected patients. The clinician should select the appropriate technique based on the patients injury pattern and expected compliance, as well as the treating surgeons experience and available resources. Larger, more well-powered studies are needed to determine equivalency between treatment methods. Acknowledgment
The authors are grateful to Louis Homer, MD, for providing the statistical analysis.

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3. Champy M, Lodde JP, Schmitt R, et al: Mandibular osteosynthesis by miniature screwed plates via a buccal approach. J Oral Maxillofac Surg 6:14, 1978 4. Chacon GE, Larson PE: Principles of management of mandibular fractures, in Miloro M, Ghali GE, Larsen PE, et al (eds): Petersons Principles of Oral and Maxillofacial Surgery (ed 2). Hamilton, BC Decker Inc, 2004, pp 401-431 5. Fordyce AM, Hildreth AJ, Carton AT, et al: Intermaxillary xation is not usually necessary to reduce mandibular fractures. Br J Oral Maxillofac Surg 37:52, 1999 6. Dimitroulis G: Management of fractured mandibles without the use of intermaxillary wire xation. J Oral Maxillofacial Surg 60:1435, 2002 7. Gear AJ, Apasova E, Schmitz JP, et al: Treatment modalities for mandibular angle fractures. J Oral Maxillofac Surg 63: 655, 2005 8. Gaujac C, Ceccheti M, Yonezaki F, et al: Comparative analysis of 2 techniques of double gloving protection during arch bar placement for intermaxillary xation. J Oral Maxillofac Surg 65:1922, 2007 9. Thor A, Andersson L: Interdental wiring in jaw fractures: Effects on teeth and surrounding tissues after a one-year followup. Br J Oral Maxillofac Surg 39:398, 2001 10. Lello JL, Lello GE: The effect of interdental continuous loop wire splinting and intermaxillary xation on the marginal gingiva. Int J Oral Maxillofac Surg 17:249, 1988 11. Arthur G, Berardo N: A simplied technique of maxillomandibular xation. J Oral Maxillofac Surg 47:1234, 1989 12. Schneider AM, David LR, De Franzo AJ, et al: Use of specialized bone screws for intermaxillary xation. Ann Plast Surg 44:154, 2000 13. Gordon KF, Reed JM, Anand VK: Results of intraoral cortical bone screw xation technique for mandibular fractures. Otolaryngol Head Neck Surg 113:248, 1995 14. Foccia R, Tavolaccini A, DellAcqua A, et al: An audit of mandibular fractures treated by intermaxillary xation using intraoral cortical bone crews. J Craniomaxillofac Surg 33:251, 2005 15. Coburn DG, Kennedy DW, Hodder SC: Complications with intermaxillary xation screws in the management of fractured mandibles. Br J Oral Maxillofac Surg 40:241, 2002 16. Coletti DP, Salama A, Caccamese JF Jr: Application of intermaxillary xation screws in maxillofacial trauma. J Oral Maxillofac Surg 65:1746, 2007 17. ManagChaushu G, Manor Y, Shoshani Y, et al: Risk factors contributing to symptomatic plate removal in maxillofacial trauma patients. Plast Reconstr Surg 105:521, 2000 18. Murthy AS, Lehman JA Jr: Symptomatic plate removal in maxillofacial trauma: A review of 76 cases. Ann Plast Surg 55:603, 2005 19. Ellis E 3rd, Walker LR: Treatment of mandibular angle fractures using one noncompression miniplate. J Oral Maxillofac Surg 54:864, 1996

References
1. Ellis E 3rd: Treatment methods for fractures of the mandibular angle. Int J Oral Maxillofac Surg 28:243, 1999 2. Michelet FX, Deymes J, Dessus B: Osteosynthesis with miniaturized screwed plates in maxillo-facial surgery. J Maxillofac Surg 1:79, 1973