J Oral Maxillofac Surg

60:642-645, 2002
Use of a 2.0-mm Locking Plate/Screw
System for Mandibular Fracture Surgery
Edward Ellis III, DDS, MS,* and John Graham, DDS, MD
Purpose: In this study, we examined the use of a 2.0-mm locking bone plate/screw system in
mandibular surgery.
Patients and Methods: All patients who were treated with a 2.0-mm locking bone plate/screw system
during an 8-month period for fractures of the mandible or other defects of the mandible were prospec-
tively studied. Ease of use of locking plate/screw system, characteristics of the fractures and defects, and
complications were tabulated.
Results: A total of 80 fractures in 59 patients were treated with the 2.0-mm locking plate/screw system.
One hundred two 2.0-mm locking plates were applied to the 80 fractures; 58 fractures received 1 plate
and 22 fractures received 2 plates. There were no intraoperative difculties associated with their
application. Fracture reductions were considered to be excellent in all cases. At the latest follow-up, all
fractures had healed, but 2 patients had slight malocclusions. Six patients developed postsurgical
infections. Only 1 patient required hospitalization for treatment of the infection; all others were managed
in the outpatient clinic. Four patients required removal of their plates for varying reasons.
Conclusions: The use of a 2.0-mm locking plate/screw system was found to be simple and to provide
sound xation in all cases.
2002 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 60:642-645, 2002
Various types of bone-plating systems have been de-
veloped to provide stable xation for mandibular frac-
tures and osteotomies. A disadvantage of conven-
tional bone plate/screw systems is that the plate must
be perfectly adapted to the underlying bone to pre-
vent alterations in the alignment of the segments and
changes in the occlusal relationship. The introduction
of locking plate/screw reconstruction plating systems
for the treatment of mandibular fractures and conti-
nuity defects has offered certain advantages over
other plating systems.
1-4
These plates function as in-
ternal xators, achieving stability by locking the
screw to the plate. A unique advantage to locking
screw/plate systems is that it becomes unnecessary
for the plate to have intimate contact with the under-
lying bone, making plate adaptation easier.
Recently, a 2.0-mm bone plate/screw system be-
came available with a simple locking mechanism be-
tween the plate and the screw (2.0-mm Mandible
Locking Plate System; Synthes Maxillofacial, Paoli,
PA). The hole in the bone plate was engineered to
accept screws that lock to it by a second thread under
the head of the screw (Fig 1). Three different thick-
nesses of the plates are available, all in various
lengths, and all accepting the same 2.0-mm diameter
screws (Fig 2). The purpose of this prospective study
was to review our experience with this new locking
bone plate/screw system.
Methods
The 2.0-mm locking plate and screw system was
applied to a consecutive series of patients undergoing
mandibular surgery during an 8-month period. Those
who had at least 6 weeks of follow-up were included
in this study; 6 weeks of follow-up was chosen be-
cause most fractures will be healed by this time and
because most major complications will present before
then. All of the patients had sustained fractures, and
the 2.0-mm locking plates were applied in all cases
unless there was comminution, in which case a
2.4-mm locking reconstruction bone plate was ap-
plied.
The patients were prospectively evaluated for the
following information: 1) location of fracture; 2)
Received from the Division of Oral and Maxillofacial Surgery, Uni-
versity of Texas Southwestern Medical Center, Dallas, TX.
*Professor.
Former Resident.
Address correspondence and reprint requests to Dr Ellis: Divi-
sion of Oral and Maxillofacial Surgery, University of Texas South-
western Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-
9109; e-mail: Edward.Ellis@UTSouthwestern.edu
2002 American Association of Oral and Maxillofacial Surgeons
0278-2391/02/6006-0007$35.00/0
doi:10.1053/joms.2002.33110
642
when present, the type of fracture (ie, comminuted vs
linear, oblique vs straight, displaced vs nondisplaced,
infected vs noninfected); 3) the presence of addi-
tional mandibular fractures; 4) presence of a tooth in
the line of fracture; 5) extraction of tooth in the line
of fracture; 6) times between injury and presentation/
injury and treatment; 7) complications during sur-
gery; 8) postsurgical occlusal relationship; 9) ade-
quacy of reduction on postsurgical radiographs; and
10) postsurgical complications, dened as the need
for further intervention of any sort.
The technique for application of the 2.0-locking
plates is not different than the application of any
other noncompression type of miniplate. The only
exception is that one should use a drill guide to
center the drill hole with the center of bone plate to
facilitate screw locking with the plate. When applying
a plate across the external oblique ridge for angle
fractures, it was found that application could be facil-
itated by rst applying 1 nonlocking screw to hold the
plate to bone while the other screws were placed. All
dentate patients were placed into maxillomandibular
xation during the surgery before application of the
bone plates. No patients were placed into postsurgi-
cal maxillomandibular xation. All dentate patients in
this study had their plates placed via a transoral ap-
proach, occasionally with the aid of a transbuccal
trocar.
Results
Sixty-one consecutive patients underwent applica-
tion of the 2.0-mm locking plates, but 2 had no follow-
up, so they are not included. Of the 59 patients who
did have at least 6 weeks of follow-up, there were 6
females and 50 males (mean SD age, 33.2 12.7
years; age range, 15 to 88 years). Twenty-three pa-
tients were non-Hispanic whites, 20 were African
Americans, and 16 were Hispanic. The cause was
assault in 46 patients, motor vehicle collisions in 8,
falls in 4, and industrial accident in 1. Patients pre-
sented to the hospital an average of 1.6 days after
injury (SD, 2.4 days; range, 0 to 10 days). The time
from injury to treatment ranged from a few hours to
15 days, with a mean SD of 4.4 3.2 days.
A total of 113 fractures occurred in the 59 patients.
Single fractures occurred in 19 patients, double frac-
tures occurred in 36, and triple fractures occurred in
4. Not all fractures were treated using the 2.0-mm
locking plates because some condylar process frac-
tures were treated closed and others were treated
with 2.4-mm locking reconstruction plates. A total of
80 of the 113 fractures in the 59 patients were treated
with the 2.0-mm locking plate/screw system; these
are the fractures for which the data have been tabu-
lated.
Three of the fractures were comminuted; the re-
mainders were linear. Sixty-ve of the fractures had at
least 1 tooth in the fracture line; 15 had no tooth
associated with the fracture. Of the 65 fractures asso-
ciated with a tooth, removal of the tooth or teeth
occurred in 28 cases and the tooth or teeth were left
in 37 fractures. Two of the patients were edentulous;
1 sustained a single fracture, and the other sustained
a double fracture. Two of the fractures were grossly
infected before treatment was provided.
One hundred two 2.0-mm locking plates were ap-
plied to the 80 fractures; 58 fractures received 1 plate,
and 22 received 2 plates (Table 1). The anatomic
distribution of the fractures in which the plates were
applied was 5 on the condylar process (4 right, 1 left),
30 on the angle (10 right, 20 left), 24 on the body (14
right, 10 left), and 19 on the symphysis. Of the 102
plates used, 63 were 4-hole miniplates, 22 were
6-hole miniplates, 5 were 4-hole broad miniplates (all
applied on the condylar process), and the remainder
FIGURE 1. The 2.0-mm locking screw and plate system, showing the
threads under the head of the screw that lock into threads within the
hole in the plate.
FIGURE 2. Three sizes of locking plates. All accept the same 2.0-mm
diameter screw.
ELLIS AND GRAHAM 643
were 2.0-mm locking reconstruction plates (two
4-hole, one 5-hole, ve 6-hole, two 7-hole, and two
8-hole plates). All fractures of the angle received a
single bone plate. Thirteen fractures of the body re-
ceived 1 plate, 7 received 2 plates, and 4 received 1
locking reconstruction plate of 2.0 mm. One fracture
of the symphysis received 1 plate, 14 received 2
plates, and 6 received a single 2.0-mm locking recon-
struction plate.
After application of the bone plates, all fractures
appeared to be well reduced and stable. There were
no intraoperative difculties associated with place-
ment of the xation hardware. Postoperative radio-
graphs taken within the rst 2 days showed excellent
reduction in all cases, with alignment of the osseous
borders of the mandible and inferior alveolar canal,
when crossed by the fracture.
Follow-up ranged from 6 to 71 weeks, with a mean
of 19 weeks. At the latest follow-up, all patients ex-
cept 2 had what appeared to be the pretrauma occlu-
sal relationship. Two patients had a residual maloc-
clusion that was not treated because of patient
preference. Both patients had a combination of sym-
physis and contralateral angle fractures, and both de-
veloped a 1- to 2-mm opening between the anterior
teeth that in one case was symmetric and in the other
case was unilateral. Final radiographs showed normal
healing in all patients except 1, who had developed
an infection of her angle fracture. This patient had a
residual radiolucency in the fracture, with good oc-
clusal relationship and no clinical mobility across the
fracture.
Postoperative infections developed in 6 patients
(Table 1). Most were treated in the outpatient setting
with intraoral incision and drainage, irrigations, and
oral antibiotics. However, 1 patient (the patient with
the radiolucency noted earlier) developed a severe
infection that required extraoral incision and drainage
under general anesthesia, intravenous antibiotics, and
admission to the hospital. The hardware on 4 frac-
tures had to be removed because of either infection
or exposure (Table 1). All 4 patients had good occlu-
sion and healed fractures at the time of hardware
removal. Two of the bone plates were found to be
loose from the bone, with granulation tissue around
the screw-bone interface. Of interest were that all
screws except 1 was still locked to the bone plates at
the time of removal.
Discussion
Conventional bone plate/screw systems require
precise adaptation of the plate to the underlying
bone. Without this intimate contact, tightening of the
screws will draw the bone segments toward the plate,
resulting in alterations in the position of the osseous
segments and the occlusal relationship. Locking
plate/screw systems offer certain advantages over
other plates in this regard; the most signicant advan-
tage may be that it becomes unnecessary for the plate
to have intimate contact with the underlying bone in
all areas. As the screws are tightened, they lock to
the plate, thus stabilizing the segments without the
need to compress the bone to the plate. This obviates
the risk that screw insertion will alter reduction. This
theoretical advantage is certainly more important
when using large bone plates, such as reconstruction
plates, which can be very difcult to adapt perfectly
to the contours of the bone. Miniplates are much
easier to bend, so it is impossible to determine on the
basis of the results of this study whether this theoret-
ical advantage is clinically apparent.
Another theoretical advantage to the use of locking
bone plate/screw systems is that the screws are un-
likely to loosen from the bone plate. This means that
even if a screw is inserted into a fracture gap, loosen-
ing of the screw will not occur. The possible advan-
tage to this property of a locking plate/screw system
is a decreased incidence of inammatory complica-
tions from loosening of the hardware. It is known that
Table 1. TREATMENT OF FRACTURES BY REGION OF THE MANDIBLE AND INCIDENCE OF INFECTIONS AFTER
SURGERY
One 2.0-mm Locking Miniplate
Two 2.0-mm Locking
Miniplates
One 2.0-mm Locking
Reconstruction Plate
Angle (n 30) 28 0 2
Adverse outcomes 1 Infection requiring plate removal 1 Infection
Body (n 24) 13 7 4
Adverse outcomes 2 Infections, 1 requiring plate removal 1 Infection requiring
plate removal
Symphysis (n 19) 1 14 6
Adverse outcomes 1 Infection requiring
plate removal
Condylar (n 5) 5 Broad miniplates 0 0
Adverse outcomes
644 2.0-mm LOCKING PLATE/SCREW SYSTEM
loose hardware propagates an inammatory response
and promotes infection. For the hardware or a locking
plate/screw system to loosen, loosening of a screw
from the plate or loosening of all of the screws from
their bony insertions would have to occur. Both of
these are unlikely events, but they certainly can oc-
cur. In fact, 2 of the patients in this study who re-
quired plate removal experienced loosening of the
screws from the bone, with the screws still attached
to the plate. Fortunately, the fracture had healed in
both cases.
A third advantage to a locking screw/plate system is
that the amount of stability provided across the frac-
ture/osteotomy gap is greater than when standard
nonlocking screws are used. An in vitro study by
Gutwald et al
5
has shown that a 2.0-mm locking
screw/plate system provides more stability to simu-
lated mandibular fractures than does a standard
2.0-mm miniplate for which the screws do not lock to
the plate. It may therefore be possible to use smaller
plates for a given fracture with a locking system than
might be required if the screws did not lock to the
plate.
Although the possible advantages to a locking
plate/screw xation system are theoretical, whether
clinical results can be improved could not be mea-
sured in this study. To show real improvements in
outcomes over conventional nonlocking xation sys-
tems requires a prospective study that compares one
xation system with the other.
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