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J Oral Maxillofac Surg

68:2743-2754, 2010

A Prospective Study of 3 Treatment


Methods for Isolated Fractures of the
Mandibular Angle
Edward Ellis III, DDS, MS*

Purpose: The purpose of this investigation was to evaluate treatment outcomes prospectively when
isolated fractures of the mandibular angle are treated by 1) nonrigid fixation that includes 5 to 6 weeks
of maxillomandibular fixation, 2) nonrigid but functionally stable fixation using a single miniplate, and
3) rigid fixation using 2 miniplates.
Patients and Methods: All patients treated for isolated fractures of the mandibular angle at Parkland
Hospital over a 12-year period were treated by 1 of the 3 methods sequentially assigned. Demographic,
fracture characteristic, and treatment and outcome data were prospectively collected and statistically
analyzed to determine whether the 3 treatments produced different outcomes.
Results: One hundred eighty-five patients had sufficient follow-up for inclusion in this study. There
were no significant differences in demographic data for the 3 groups. There were significant differences
in treatment outcomes for several variables, including the amount of time it took to perform the surgery
and postoperative wound problems.
Conclusion: The use of single miniplate was the easiest to perform and was associated with the lowest
number of complications.
© 2010 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 68:2743-2754, 2010

The treatment of mandibular angle fractures is plagued provide such rigidity.6-8,15-19 Primary bone union, which
with the highest postsurgical complication rate of all necessitates absolute immobility of fragments, is the
mandibular fractures.1-5 Even traditional treatment goal of treatment of mandibular fractures by these sur-
methods have a high complication rate (17%) in some geons.
patient populations.5 Plate and screw fixation devices In 1973, Michelet et al20 reported the treatment of
have revolutionized the treatment of angle fractures; mandibular fractures using small, easily bendable non-
however, complication rates vary widely from one compression bone plates, placed transorally, attached
center to another6-9 and from one fixation scheme to with monocortical screws. Champy et al9 performed
another.10-14 several investigations with a “miniplate” system to
There are 2 general philosophies espoused by users of validate the technique. In their experiments, they
plate and screw fixation for mandibular fractures. One determined the “ideal line of osteosynthesis” for frac-
group believes that plate and screw fixation should tures of the mandibular angle is the positioning of the
provide sufficient rigidity to the fragments to prevent plate along the superior border of the mandible. Un-
interfragmentary mobility during active use of the man- like in some surgeries, absolute immobilization of
dible (rigid fixation). This group recommends placing bone fragments and primary bone union was deemed
large bone plates fastened with bicortical bone screws, unnecessary. This technique of fixation could be cat-
1 large and 1 small bone plate, or 2 small plates to egorized as nonrigid, but because the patient did not
have to have immobilization of the jaws, it could also
be categorized as “functionally stable fixation.” Clini-
*Professor, Oral and Maxillofacial Surgery, The University of cal studies have proven the usefulness of this tech-
Texas Health Science Center at San Antonio, San Antonio, TX. nique.14,20-30
Supported by a grant from AO North America. The controversy still rages between advocates of
Address correspondence to Dr Ellis: University of Texas Health “rigid” fixation, which usually requires application of 2
Science Center, 7703 Floyd Curl Dr, MC 7908, San Antonio, TX bone plates, and those who use nonrigid but function-
78229-3400; e-mail: ellise3@uthscsa.edu ally stable fixation by application of a single miniplate.
© 2010 American Association of Oral and Maxillofacial Surgeons However, there are those who believe that the time-
0278-2391/10/6811-0015$36.00/0 honored nonrigid method for treatment of angle frac-
doi:10.1016/j.joms.2010.05.080 tures is preferred, using either closed or open reduction

2743
2744 ISOLATED FRACTURES OF THE MNDIBULAR ANGLE

and internal fixation with a transosseous wire plus sev- Table 1. DATA COLLECTED ON PATIENTS
eral weeks of maxillomandibular fixation (MMF).30
Certainly, if a single miniplate can provide similar or Demographic Variables
better results than the application of 2 bone plates, there Age
will be cost savings both from the savings in hardware Gender
and from the time in surgery necessary to apply the Race
Medical issues, including: presence of diabetes, steroid use,
second bone plate. If the patient can return to normal human immunodeficiency virus, chemotherapy, radiation
daily activities sooner when using plate or screw fixa- therapy, nutritional deficiencies, alcohol use (quantity,
tion (or a combined method), the cost to society of such frequency), intravenous and nonintravenous drug use
(quantity, frequency)
injuries will be minimized. American Society of Anesthiology classification
It is unclear on the basis of clinical studies whether Cause of injury (altercation, motor vehicle, sport, fall,
absolute rigid fixation should be used. Studies that favor occupational, other)
one method of fixation over another are available. The Fracture Characteristics
problem with most of the clinical studies in the litera- Side of fracture (right vs left)
ture is that they are retrospective, nonrandomized, and Contamination of fracture (open vs closed)
Displacement (non, minimal, moderate, severe)
may include patients who also have fractures of other Presence of tooth in line of fracture
regions of the mandible in addition to the angle. The Location of tooth in fracture (proximal vs distal segment)
purpose of this prospective study was to determine Eruption status of tooth in line of fracture (impacted, partially
erupted, erupted)
whether there is any difference in outcomes when iso- Mobility of tooth in line of fracture (mobile, nonmobile)
lated fractures through the angle of the mandible are Presence of pericoronitis of tooth in line of fracture
treated with nonrigid fixation and 5 to 6 weeks of MMF, Fracture of tooth in line of fracture (yes, no)
Decay in tooth in line of fracture (yes, no)
functionally stable but nonrigid fixation with a single Periodontitis of tooth in line of fracture (yes, no)
miniplate, or rigid fixation using 2 miniplates. Amount of root exposure to fracture (minimal, up to 0.5 of root,
most/all of root)
Neurosensory deficit of mental nerve (none, hypesthetic,
Patients and Methods anesthetic, dysesthetic)
Treatment Variables
All dentate patients 13 years or older with isolated
Treatment group
(ie, no other mandibular or maxillary), noncommi- Duration between injury and presentation
nuted fractures through the mandibular angle who Duration between injury and surgical treatment
presented for treatment at Parkland Hospital between Duration between injury and receiving antibiotics
Duration between surgery and discharge
April 1997 and July 2009 were included in this insti- Removal of tooth in line of fracture (yes, no)
tutional review board–approved study. To be in- Surgical time from incision to last suture (and to the application
cluded, they must have had sufficient dentition to of maxillomandibular fixation in the nonrigid group)
Surgeon’s assessment of ease of application of fixation device(s)
determine proper occlusion. Exclusion criteria in- (simple, some difficulty, very difficult)
cluded 1) the fracture was infected at the time of Postoperative radiographic evaluation of reduction (good,
treatment, 2) medical conditions that could possibly moderate, poor)
have interfered with healing (HIV positivity, diabetes, Outcome Variables
chemotherapy, etc) or prevented general anesthesia, Short-term evaluation of occlusion (normal, malocclusion)
and 3) less than 6 weeks of follow-up. Use of elastics to treat any malocclusion (yes, no)
Wound problems (cellulitis, purulence, dehiscence of incision,
Patients were sequentially assigned to 1 of 3 treat- plate exposure, granulation tissue at incision) (yes, no)
ment groups: 1) nonrigid fixation using open reduc- Time between surgery and wound problem
tion and internal wire fixation plus 5 to 6 weeks of Need for treatment of any complication (yes, no)
Methods of treatment for any complication including type of
MMF, 2) open reduction and internal fixation using a anesthesia (local, general), location where complication was
single miniplate attached along the superior border of treated (ie, clinic, operating room, etc), need for hardware
the mandible using at least 2 2.0-mm-diameter screws removal, etc)
Follow-up duration
on each side of the fracture, 3) open reduction and Occlusion at last follow-up visit (normal, malocclusion)
internal fixation using 2 miniplates, 1 at the superior Assessment of fracture fragment alignment in latest radiograph
border and 1 along the inferior border of the mandi- (good, moderate, poor)
Interincisal dimension at latest follow-up
ble, attached with at least 2 2.0-mm-diameter screws Clinical union at latest follow-up (yes, no)
on each side of the fracture. Palpability of hardware at latest follow-up (yes, no)
Data were prospectively collected (Table 1) on the Neurosensory dysfunction of mental nerve at latest follow-up
(none, hypoesthetic, anesthetic, dysesthetic)
patients and their treatment using a data collection Total no. of postoperative visits
form. The data were then input into a Microsoft Excel
spreadsheet (Microsoft, Redmond, WA). Descriptive Edward Ellis III. Isolated Fractures of the Mndibular Angle. J Oral
and inferential statistics were performed using XLSta- Maxillofac Surg 2010.
tistics (version 08.05.12, 1997-2008, Rodney Carr, free-
EDWARD ELLIS III 2745

ware available at rodneyc@deakin.edu.au). Compara- The most posterior screw, which was on the medial
tive statistics of nonparametric categorical variables surface of the mandibular ramus, was in some cases
was performed using ␹2 cross-table analysis. Compar- inserted after removing the MMF, allowing instrumen-
ative statistics of parametric data were performed tation between the upper and lower teeth from the
using 1-way analysis of variance. If a difference ex- opposite side. After the plate was placed, MMF wires
isted, post hoc t tests were performed to compare the were removed, and the occlusion was checked. Post-
individual groups. Differences were considered statis- surgical MMF was not used in any patient. The inci-
tically significant if the confidence interval was P less sion was closed with resorbable suture, and no drains
than .05. were placed.

SURGICAL TECHNIQUES Two Miniplates


In addition to what was just described for the single
Patients received systemic antibiotics from the time
miniplate group, a second miniplate was adapted and
of presentation. The fractures were not considered
screwed to the inferior portion of the buccal cortex
medical emergencies and were scheduled electively
using 2.0-mm screws. This required much more sub-
when operating room time permitted, but usually
periosteal dissection to expose the inferior border of
within 1 or 2 days after presentation.
the mandible. The screws were self-threading and
Nonrigid Fixation placed through a transbuccal trochar. After the plates
After placement of arch bars, the fracture was ex- were placed, MMF wires were removed, and the oc-
posed using an intraoral incision. Only the amount of clusion was checked. Postsurgical MMF was not used
soft tissue stripping necessary to visualize, reduce, in any patient. The incision was closed with resorb-
and stabilize the fracture was performed. Mobile teeth able suture, and no drains were placed.
or teeth with apices that were exposed in the fracture
Postsurgical Management
were removed. If teeth in the fracture site were to be
Antibiotics were continued through the periopera-
extracted, the intraoral incision included the attached
tive period and for 5 to 7 days after surgery. For
gingiva around the involved tooth. A Kirschner or
patients not allergic to penicillin, an intramuscular
C-wire was inserted through the skin (without a tro-
depot injection (1 million U) of procaine penicillin G
char) and used to drill a hole through the mandible on
was administered before the patient was awakened
each side of the fracture, usually into the socket
from anesthesia so that compliance with antibiotic
where a tooth had been extracted. Otherwise, the
use would not be a factor. For those patients allergic
hole was created through both the buccal and lingual
to penicillin, an oral regimen of clindamycin was
cortices. A 24-gauge wire was then passed between
prescribed. Chlorhexidine mouth rinse was provided
the fragments and twisted together with the fracture
for all patients. Dietary consultation for patients
reduced and the patient’s mandible held in MMF. The
placed into postsurgical MMF was provided. For pa-
wire was cut and the end adapted to the outer cortex.
tients not placed into MMF, no dietary recommenda-
The soft tissue flap was undermined, and closure was
tions were made. For patients in MMF, the wires were
performed with resorbable suture. No drains were
removed at 5 weeks, but the arch bars were left in
used. Postsurgical MMF was secured using 3 or 4
place. Arch bar removal for all patients occurred once
24-gauge wires around the arch bars.
their interincisal opening was 40 mm or greater. Elas-
Single Miniplate tics were not used unless the patient had a malocclu-
After placement of arch bars, the fracture was ex- sion that required occlusal guidance. They were used
posed using an intraoral incision. Only the amount of only as long as necessary to obtain the proper occlusal
soft tissue stripping necessary to visualize, reduce, relationship.
and stabilize the fracture was performed. Mobile teeth
or those with apices exposed in the fracture were
Results
removed. If teeth in the fracture site were to be
extracted, the intraoral incision included the attached Two hundred twenty-eight patients were enrolled
gingiva around the involved tooth. The fracture was in the study, but 43 were not operated on with the
then reduced and the jaws placed into MMF. A 4-hole author available, were lost during the follow-up pe-
noncompression titanium miniplate (Synthes Maxillo- riod, or never returned for an evaluation at the 6-week
facial, Paoli, PA; or Walter Lorenz Surgical, Jackson- period or later. The final study sample included 185
ville, FL) was adapted along the medial side of the patients with 60 in group 1, 62 in group 2, and 63 in
external oblique ridge and screwed to the bone using group 3. The demographics of the population are
2.0-mm self-threading screws. No transbuccal trochar presented in Table 2. Not surprisingly, males greatly
was necessary for instrumentation. The 3 most ante- outnumbered females (161 vs 24), and the mean age
rior screws were inserted with the patient in MMF. was in the 20- to 30-year-old range. African Americans
2746 ISOLATED FRACTURES OF THE MNDIBULAR ANGLE

Table 2. DEMOGRAPHIC VARIABLES BY GROUP

Treatment Group
1 (nonrigid) 2 (1 miniplate) 3 (2 miniplates) Significance

n 60 62 63
Gender Male: 51 Male: 55 Male: 55 ns
Female: 9 Female: 7 Female: 8
Age (years) x ⫽ 27.4 (range 14-49) x ⫽ 28.5 (range 13-51) x ⫽ 27.8 (range 17-54) ns
Race White: 21 White: 18 White: 19 ns
Hispanic: 12 Hispanic: 17 Hispanic: 21
AA: 27 AA: 27 AA: 23
Cause Altercation: 42 Altercation: 48 Altercation: 44 ns
Fall: 7 Fall: 3 Fall: 3
Sport: 3 Sport: 4 Sport: 7
MVC: 3 MVC: 5 MVC: 6
Occupational: 1 Occupational: 0 Occupational: 1
Other: 4 Other: 2 Other: 2
x ⫽ 1.13 range ⫽ 0-12 x ⫽ 2.29 range ⫽ 0-12 x ⫽ 1.98 range ⫽ 0-12
Alcohol (drinks/day) SD 2.1 SD 3.5 SD 2.7 ns
x ⫽ 5.03 range ⫽ 0-30 x ⫽ 5.13 range ⫽ 0-25 x ⫽ 5.30 range ⫽ 0-30
Alcohol (years of use) SD 7.5 SD 6.9 SD 7.2 ns
IV drug use No 60 No 61 No 60 ns
(currently) Yes: 0 Yes: 1 Yes: 3
IV drug use (ever) No 57 No 58 No 60 ns
Yes: 3 Yes: 4 Yes: 3
Non-IV drug use No 8 No 11 No 14 ns
(currently) Yes: 52 Yes: 51 Yes: 49
ASA I: 32 I. 34 I. 39 ns
II: 28 II. 28 II. 21
III: 0 III. 0 III. 3
Abbreviations: AA, African American; ASA, American Society of Anesthesiology; IV, intravenous; MVC, motor vehicle collision.
Edward Ellis III. Isolated Fractures of the Mndibular Angle. J Oral Maxillofac Surg 2010.

were the most common racial group (n ⫽ 77), fol- 88%), and most were minimally or moderately dis-
lowed by whites (n ⫽ 58) and Hispanics (n ⫽ 50). placed (160/185%, 86%). Teeth were present in the
Also not surprisingly, the vast majority of fractures line of the angle fracture in most cases (167/185%,
were sustained in altercations (n ⫽ 134), followed by 90.3%) and were relatively equally distributed be-
sports and motor vehicle accidents (n ⫽ 14 each), tween being contained within the proximal and distal
falls (n ⫽ 13), other causes (n ⫽ 8), and occupational segments. The teeth were more often mobile than not
accidents (n ⫽ 2). Medical conditions of the patients (n ⫽ 114/185; 61%) and were fractured in 30 (16%)
were few. Only 1 patient had taken steroids and that cases. Just over half were erupted or partially erupted
was over a year before surgery, 1 patient was diabetic, (107/185%, 57.8%), but even the ones classified as
there were no cases of human immunodeficiency impacted were rarely completely encased in bone. In
virus, chemotherapy, radiation therapy, or obvious those cases of teeth involved in the fracture (n ⫽
nutritional deficiencies. Alcohol use was common, as 167), the teeth were not commonly decayed (23/167,
was a history of nonintravenous drug use. However, 14%) or periodontally involved (27/167, 16%) and
few patients had a history of intravenous-drug use only occasionally had pericoronitis (13/167, 8%). The
(n ⫽ 10). The vast majority of patients were classified amount of root exposed to the fracture was variable,
as ASA I or II, with only 3 patients classified as III, and but in the majority of instances, from half to the entire
no IVs or Vs. There was no statistically significant root was completely exposed to the fracture site and
difference in any of the demographic variables among devoid of bone (114/167, 68%). Neurosensory deficits
the treatment groups. of the mental nerve were quite variable, and the patient
The variables describing the characteristics of the was often anesthetized before surgery. Patients rarely
fracture are presented in Table 3. Given that alterca- presented immediately after their injury. The average
tions were the most common cause of fractures, it patient arrived 2 days after injury, and therefore anti-
should not be surprising that the majority were on the biotics were not begun until that time. The duration
left side (n ⫽ 124/185; 67%). Most were considered between injury and surgical treatment was much
compound, or open to the oral cavity (n ⫽ 163/185; longer, averaging 5.2 days with a range of 0 to 29
EDWARD ELLIS III 2747

Table 3. FRACTURE CHARACTERISTICS BY GROUP

Treatment Group
1 (nonrigid) (n ⫽ 60) 2 (1 miniplate) (n ⫽ 62) 3 (2 miniplates) (n ⫽ 63) Significance

Side of Fx Left: 45 Left: 38 Left: 41 ns


Right: 15 Right: 22 Right: 22
Open versus closed Fx Open: 52 Open: 56 Open: 55 ns
Closed: 8 Closed: 4 Closed: 7
Displacement None: 5 None: 3 None: 7 ns
Minimal: 30 Minimal: 36 Minimal: 30
Moderate: 25 Moderate: 16 Moderate: 23
Severe: 0 Severe: 5 Severe: 3
Tooth in Fx No 9 No 3 No 4 ns
Yes: 51 Yes: 57 Yes: 59
Tooth in which segment? Proximal: 25 Proximal: 28 Proximal: 25 ns
Distal: 26 Distal: 29 Distal: 34
Position of tooth Erupted: 14 Erupted: 17 Erupted: 23 ns
Partial: 13 Partial: 17 Partial: 23
Impacted: 24 Impacted: 23 Impacted: 13
Tooth mobility Mobile: 33 Mobile: 40 Mobile: 41 ns
Nonmobile: 18 Nonmobile: 17 Nonmobile: 18
Fracture of tooth No: 41 No: 46 No: 50 ns
Yes: 10 Yes: 11 Yes: 9
Pericoronitis No: 50 No: 53 No: 51 ns
Yes: 1 Yes: 4 Yes: 8
Tooth decayed? No: 46 No: 49 No: 49 ns
Yes: 5 Yes: 8 Yes: 10
Periodontitis of tooth? No: 42 No: 49 No: 49 ns
Yes: 9 Yes: 8 Yes: 10
Amount of root exposed to Fx Minimal: 17 Minimal: 19 Minimal: 19 ns
Up to half: 20 Up to half: 24 Up to half: 23
Most or all: 14 Most or all: 14 Most or all: 17
Neurosensory deficit before None: 24 None: 24 None: 29 ns
surgery Hypesthetic: 29 Hypesthetic: 33 Hypesthetic: 31
Anesthetic: 7 Anesthetic: 5 Anesthetic: 3
Duration between injury and x ⫽ 2.60 range ⫽ 0-21 x ⫽ 2.18 range ⫽ 0-28 x ⫽ 1.44 range ⫽ 0-12 ns
presentation (days) SD ⫽ 4.0 SD ⫽ 4.3 SD ⫽ 2.3
Duration between injury and x ⫽ 2.59 range ⫽ 0-21 x ⫽ 2.05 range ⫽ 0-28 x ⫽ 1.77 range ⫽ 0-12 ns
antibiotic administration (days) SD ⫽ 3.8 SD ⫽ 4.3 SD ⫽ 2.4
Duration between injury and x ⫽ 5.52 range ⫽ x ⫽ 5.36 range ⫽ x ⫽ 4.73 range ⫽ ns
surgery (days) 1-22 SD ⫽ 4.0 1-29 SD ⫽ 4.9 0-19 SD ⫽ 3.5
Abbreviation: Fx, fracture.
Edward Ellis III. Isolated Fractures of the Mndibular Angle. J Oral Maxillofac Surg 2010.

days. None of the fracture characteristic variables clearly rated group 2 as being easier surgeries to
among the treatment groups were statistically signif- perform than those of groups 1 or 3 (P ⬍ .001).
icantly different from one another. The analysis of outcomes is presented in Table 5.
The variables describing the treatment provided to The time between surgery and discharge averaged 1
the patients are presented in Table 4. During the day, with a range of 0 to 11 days. The duration of
surgery, 150 of the 167 teeth present in the line of the follow-up averaged 162 days with no significant dif-
angle fracture were extracted (89.8%), with no differ- ference among the groups. Analysis of the immediate
ence among the groups. The time required to provide postoperative radiograph showed good reduction of
surgical treatment in the operating room varied from the fracture in the vast majority of cases (166/185,
13 to 70 minutes, with an average of 29.5 minutes. 89.7%). There was no statistically significant differ-
There was a statistically significant difference among ences among the treatment groups for this variable.
the groups for the duration of surgery (P ⬍ .001) with Wound problems were encountered in 25 patients, 9
group 2 having the shorter time (x ⫽ 23.5 minutes), in group 1, 2 in group 2, and 14 in group 3 (Table 6).
followed by group 1 (x ⫽ 27.8 minutes). Group 3 had There was a statistically significant difference in the
the longest time (x ⫽ 37 minutes). The surgeons occurrence of a postoperative wound problem among
2748 ISOLATED FRACTURES OF THE MNDIBULAR ANGLE

Table 4. TREATMENT VARIABLES BY GROUP

Treatment Group
1 (nonrigid) (n ⫽ 60) 2 (1 miniplate) (n ⫽ 62) 3 (2 miniplates) (n ⫽ 63) Significance

Extraction of No: 2 No: 7 No: 8 ns


tooth in Fx? Yes: 49 Yes: 50 Yes: 51
Surgical time x ⫽ 27.8 range ⫽ 14-70 x ⫽ 23.5 range ⫽ 13-54 x ⫽ 37.0 range ⫽ 21-68 Overall: P ⬍ .001
(min) SD ⫽ 9.04 SD ⫽ 7.9 SD ⫽ 9.6 Groups 1 and 2: P ⬍ .01
Groups 1 and 3: P ⬍ .001
Groups 2 and 3: P ⬍ .001
Ease of surgery Simple: 32 Simple: 57 Simple: 27 Overall: P ⬍ .001
Some difficulty: 23 Some difficulty: 5 Some difficulty: 27 Groups 1 and 2: P ⬍ .001
Difficult: 5 Difficult: 0 Difficult: 9 Groups 1 and 3: ns
Groups 2 and 3: P ⬍ .001
Abbreviation: Fx, fracture.
Edward Ellis III. Isolated Fractures of the Mndibular Angle. J Oral Maxillofac Surg 2010.

the groups (P ⬍ .01). Eighteen of the 25 patients with Discussion


wound problems required removal of their internal
Over the course of several years, we performed vari-
fixation device(s) (5 of 9 in group 1, 1 of 2 in group
2, 11 of 14 in group 3). Seven of 18 times, this could ous treatment schemes for fractures of the mandibular
be performed in the clinic under local anesthesia, but angle on a consecutive series of patients.5,10-14,31-35 In
the remainder had to have a general anesthesia in the one of those studies, we showed that treatment of
operating room to remove the hardware. This was angle fractures even using traditional methods—
especially common in group 3, in whom 7 of 11 closed reduction and/or open reduction and internal
patients who required hardware removal required a wire fixation—produced a high rate of complication
general anesthetic to do so. Although incision and (17%) in our patient population.5 The most useful
drainage procedures were performed from both intra- techniques in our population were either an extraoral
and extraoral approaches, hardware removal was al- open reduction and internal fixation with the AO/
ways performed through an intraoral approach. Fig- ASIF reconstruction plate,11 or intraoral open reduc-
ures 1 and 2 show representative cases of complica- tion and internal fixation using a single miniplate.14
tions. The use of the reconstruction bone plate was also
Wound problems occurred at various times after found to result in few complications in a study of
surgery but averaged 3 weeks of more. There was no angle fractures by Iizuka and Lindqvist.36 However,
statistically significant difference between the time the application of this plate for fractures of the angle
between surgery and discovery of a wound problem of the mandible is much easier through an extraoral
among the 3 groups. At the last postoperative visit, approach, an approach that can create its own set of
there were 7 cases of malocclusion, none of which complications (eg, facial nerve injury, scars, etc). For
were in group 2. However, there was no significant these reasons, we currently use transoral approaches
difference among the groups. Interestingly, there
in the vast majority of fractures through the mandib-
were many more cases (n ⫽ 22) of fracture mobility
ular angle, and most commonly, a single 2.0-mm
detected at latest follow-up (P ⬍ .01), but most of
miniplate is used along the superior border as advo-
these were extremely minor. Not surprisingly, group
cated by Champy.9
1 had the largest number of cases in which some
The results of the consecutive series of clinical
movement at the fracture site with bimanual manip-
ulation could be detected (n ⫽ 14). The maximum investigations performed in our hospital on a similar
interincisal dimension at last follow-up averaged over patient population indicate that, contrary to popular
40 mm in all 3 groups, although there was a signifi- belief, up to a point, the incidence of major compli-
cant difference among them (P ⬍ .05), with group 1 cations after fractures of the mandibular angle are
having a slightly lower mean value than the others. inversely proportional to the rigidity of the fixation
There were no significant differences in the neurose- applied when an intraoral approach is used. Every
nory deficits or the radiographic interpretation of attempt we made at using a 2-plate technique via a
fracture alignment at the latest follow-up visit, nor transoral approach was fraught with high rates of
was there any difference in the number of postoper- sequestrectomy, infection, and need for subsequent
ative visits among the groups. surgery. However, this finding is not universal, and
EDWARD ELLIS III 2749

Table 5. OUTCOME VARIABLES BY GROUP

Treatment Group
1 (nonrigid) (n ⫽ 60) 2 (1 miniplate) (n ⫽ 62) 3 (2 miniplates) (n ⫽ 63) Significance

Duration between surgery x ⫽ 1.13 range ⫽ 0-11 x ⫽ 0.83 range ⫽ 0-6 x ⫽ 0.85 range ⫽ 0-2 ns
and discharge (days) SD ⫽ 1.5 SD ⫽ 0.8 SD ⫽ 0.4
Follow-up duration (days) x ⫽ 159.12 x ⫽ 131.79 x ⫽ 195.52 ns
Evaluation of immediate Good: 54 Good: 59 Good: 53 ns
postoperative x-rays Not good: 6 Not good: 3 Not good: 10
Wound problems (see n⫽9 n⫽2 n ⫽ 14Overall: P ⬍ .01
Table 6) Groups 1 and 2:
P ⬍ .05
Groups 1 and 3:
ns
Groups 2 and 3:
P ⬍ .01
Duration between surgery x ⫽ 49.3 range ⫽ 3-151 x ⫽ 61.5 range ⫽ 37-86 x ⫽ 45.14 range ⫽ 9-101 ns
and wound problem SD ⫽ 44.3 SD ⫽ 34.6 SD ⫽ 23.4
(days)
Occlusion at last follow- Good: 56 Good: 62 Good: 60 ns
up visit Malocclusion: 4 Malocclusion: 0 Malocclusion: 3
Clinical union at last No: 14 No: 5 No: 3 Overall: P ⬍ .01
follow-up visit Yes: 46 Yes: 57 Yes: 60 Groups 1 and 2:
P ⬍ .05
Groups 1 and 3:
P ⬍ .01
Groups 2 and 3:
ns
Final interincisal x ⫽ 41.21 range ⫽ x ⫽ 44.59 range ⫽ x ⫽ 43.92 range ⫽ Overall: P ⬍ .05
dimension (mm) 10-60 SD ⫽ 9.9 30-65 SD ⫽ 5.8 34-65 SD ⫽ 6.2
Groups 1 and 2:
P ⬍ .05
Groups 1 and 3:
ns
Groups 2 and 3:
ns
Neurosensory None: 32 None: 37 None: 31 ns
Dysfunction at last Hypesthetic: 11 Hypesthetic: 5 Hypesthetic: 17
follow-up visit Anesthetic: 3 Anesthetic: 1 Anesthetic: 3
Dysesthesia: 0 Dysesthesia: 0 Dysesthesia: 1
X-ray at last follow-up Good: 53 Good: 60 Good: 59 ns
visit Moderate: 3 Moderate: 1 Moderate: 3
Poor: 4 Poor: 1 Poor: 1
No. of postoperative visits x ⫽ 2.98 range ⫽ 1-8 x ⫽ 2.36 range ⫽ 1-5 x ⫽ 2.62 range ⫽ 1-9 ns
SD ⫽ 1.5 SD ⫽ 1.1 SD ⫽ 1.5
Edward Ellis III. Isolated Fractures of the Mndibular Angle. J Oral Maxillofac Surg 2010.

there are other similar studies in the literature that vides similar or better results (ie, fewer complica-
show 2 miniplates perform better than one.15,19,37 tions) when compared with other treatments.
The problem with most of the clinical studies is Because of the inherent problems in the literature
that they are series of patients treated with a certain with most studies, this prospective study was in-
technique (case series),5,10-14,16,25,31,34-37 usually ret- tended to determine whether there is any difference
rospective or may include patients who also have in outcomes when isolated fractures through the an-
fractures in other regions of the mandible in addition gle of the mandible are treated with nonrigid fixation
to the angle, such as the contralateral body or sym- and 5 to 6 weeks of MMF, functionally stable but
physis.5,10-14,16,27,31-41 The only prospective or ran- nonrigid fixation with a single miniplate, or rigid
domized studies performed on fractures through the fixation using 2 miniplates. An attempt was made to
mandibular angle include patients who have concom- control as many variables as possible. For instance, all
itant fractures elsewhere in the mandible.38-41 The cases had to have been performed with the surgeon
results of those investigations showed that single (the author) scrubbed in surgery. This eliminated sev-
miniplate fixation of mandibular angle fractures pro- eral cases from the original group of patients. Isolated
2750
Table 6. WOUND PROBLEMS BY GROUP

Plate/Wire Granulation Oral Antibiotic I&D Required? Plate/Wire Removal Location Where
Cellulitis Purulence Dehiscence Exposure Tissue Curative? (IO vs EO) Required? Managed/Anesthesia Details

Group 1 (Intraosseous Wire ⫹ MMF)


1 x x x No EO Yes hosp/GA Last follow-up showed poor reduction and
malocclusion but Fx stable
2 x x x No IO No Clinic/LA Patient cut himself out of MMF at 5 weeks;
Did not return until weeks later. Last
follow-up showed poor reduction of Fx,
malunion, and malocclusion
3 x x Patient cut himself out of MMF at 4 weeks;
ramus rotated into oral cavity. Malunion/
malocclusion; no infection; osteotomy
planned, but patient did not return for it
4 x Yes
5 x x YES Hosp/GA Union, good occlusion
6 x Yes Patient cut himself out of MMF ⫻ 2; union,
good occlusion
7 x x x Yes Union, good occlusion
8 x x x x No EO Yes Hosp/GA Nonunion, malocclusion, reconstructed
plate applied, good outcome
9 x x x x No Yes Clinic/LA Union, good occlusion
Group 2 (1 miniplate)
1 x Yes Union, good occlusion
2 x No Yes Clinic/LA Union, good occlusion
Group 3 (2 miniplates)
1 x x x x No Yes (upper plate) Clinic/LA Union, good occlusion

ISOLATED FRACTURES OF THE MNDIBULAR ANGLE


2 x Yes Yes (one loose screw) Union, good occlusion
3 x Yes Union, good occlusion
4 x x No IO Yes Hosp/GA Union, good occlusion
5 x x x Yes Union, good occlusion, imperfect reduction
6 x x x Yes Clinic/LA (upper plate only) Union, good occlusion, imperfect reduction
7 x x x x No Yes Hosp/GA At time of plate removal, Fx not healed,
malocclusion; MMF required,
subsequently union/good occlusion.
8 x x No Yes Hosp/GA Union, good occlusion
9 x x x x No Yes Hosp/GA Union, good occlusion
10 x x x x x No IO Yes Hosp/GA Union, good occlusion
11 x x x x No IO Yes Hosp/GA Union, good occlusion
12 x Yes Hosp/GA Union, good occlusion
13 x x x No IO Yes Clinic/LA Union, good occlusion
14 x x x x No IO Yes Clinic/LA At time of plate removal, Fx not healed;
MMF required, good occlusion;
subsequently healed.

Abbreviations: EO, extraoral; Fx, fracture; GA, general anaesthesia; Hosp, hospital; I&D, incision and drainage; IO, intraoral; LA, local anesthesia; MMF, maxillomandibular
fixation.
Edward Ellis III. Isolated Fractures of the Mndibular Angle. J Oral Maxillofac Surg 2010.
EDWARD ELLIS III 2751

FIGURE 1. Case of isolated left angle fracture treated with intraosseous wire plus maxillomandibular fixation (MMF). A, Preoperative
panoramic radiograph; B, intraoperative photograph after extraction of third molar and placement of intraosseous wire; C, immediately
postoperative panoramic radiograph showing intraosseous wire and MMF; D, intraoral photograph taken 9 weeks postoperatively showing
bony sequestrum (arrow); E, photograph showing abscess that developed; F, panoramic radiograph taken after debridement, wire removal,
and incision and drainage (note: MMF required); G, panoramic radiograph taken 4 weeks after sequestrectomy and debridement. The
patient had good occlusion and minimal mobility across fracture site at this time.
Edward Ellis III. Isolated Fractures of the Mndibular Angle. J Oral Maxillofac Surg 2010.
2752 ISOLATED FRACTURES OF THE MNDIBULAR ANGLE

FIGURE 2. Case of isolated left angle fracture treated with 2 miniplates. A, Preoperative panoramic radiograph; B, immediate postoperative
radiograph; C, intraoral photograph taken 4 weeks later showing swelling; D, photograph at 4 weeks showing abscess spontaneously
draining through trochar site; E, panoramic radiograph taken at 4 weeks showing radiolucency around one of the bone screws in the lower
plate (arrow); F, bone plates and sequestrum after removal; G, panoramic radiograph taken after hardware removal and sequestrectomy
(note: maxillomandibular fixation required); H, panoramic radiograph taken 4 weeks later. The patient had good occlusion and no mobility
across fracture site.
Edward Ellis III. Isolated Fractures of the Mndibular Angle. J Oral Maxillofac Surg 2010.

fractures were part of the inclusion criteria so the 2, the third patient to treatment group 3, and the
variables involved in biomechanics and treatment of a fourth patient begins the cycle again. The reason for
double fracture could be eliminated as a factor in the this is that there was an ulterior motive in treatment
outcome. Unfortunately, isolated fractures of the an- group assignment. Beyond the study being per-
gle are much less common in clinical practice than formed, an overriding desire was to have the residents
the combination of an angle and contralateral body or rotating through the Parkland Hospital service to gain
symphysis fractures, so acquisition of a sufficient sam- experience in all 3 methods of angle fracture treat-
ple took 12 years. However, it is believed that a ment. Three factors were used in making this deci-
second fracture in the mandible can confound the sion: isolated fractures of the mandibular angle are
outcome data because the fixation requirements of a extremely uncommon (average 19/year at Parkland
double fracture are often different from those for an Hospital); 2 of the treatment arms are not commonly
isolated fracture.42-44 Furthermore, if a malocclusion performed in our hospital (nonrigid fixation and 2
is noted, it is not always possible to determine which miniplates), and senior residents rotate through this
of the fractures may be contributing to the malocclu- hospital every 3 months. Therefore, the average resi-
sion. dent only treated approximately 6 patients in the
One might criticize the design of this prospective study, and by sequential assignment of treatments, it
study in that the assignment of patients to treatment could be guaranteed that each resident would treat
groups was nonrandomized. Instead, a fixed pattern approximately 2 patients in each treatment group.
of assignment of treatment was performed. In a fixed Nonrandomized assignment, although more difficult
pattern design of assigning patients in a study with 3 to implement in an unbiased manner than random-
treatment groups, the first patient is assigned to treat- ized assignment, is still a legitimate method of assign-
ment group 1, the second patient to treatment group ing patients to study groups in some circumstances.45
EDWARD ELLIS III 2753

The main advantage to randomization is that variables ered when selecting internal fixation schemes for frac-
that might affect treatment outcomes should be tures through the mandibular angle.
equally distributed to all treatment groups. The results The outcomes among the 3 groups presented here
of comparison of the demographic characteristics of are variable. At the last visit, there were not many dif-
the 3 treatment groups in this study showed no sta- ferences between the groups. Most had good occlusion,
tistically significant difference among them, indicat- good mandibular mobility, similar neurosenory func-
ing that although not ideal, the assignment of treat- tion, acceptable radiographic reductions, and so forth.
ment groups fulfilled the desire for resident education Curiously, the wire fixation group had some mobility of
as well as comparability of the demographics of the the segments to bimanual manipulation at last visit, but
treatment groups. the incidence of malocclusion was low, similar to the
There have been studies on the treatment of frac- other groups. It is likely that the mobility would dimin-
tures of the mandible that have shown that operator ish in time as the fracture further solidifies. Overall, the
experience is an important factor in treatment out- main problem using internal wire fixation or 2 bone
comes.4,46,47 There is no question that experienced plates was the high incidence of wound problems, in-
surgeons can treat injuries faster and perhaps with cluding dehiscence, infection, exposed hardware and
less surgical trauma that those who are less experi- bone, and so forth. This was strikingly dissimilar to the
enced. An important consideration about operator ex- single miniplate group, who had only 2 cases of wound
perience, however, is that it takes much less experience problems. Most of the cases of wound problem in all
to become adept at using a single miniplate than the groups required surgical intervention to control infec-
other techniques. The main difference in the treatment tion, debride devital bone, remove loose hardware,
variables for the current sample was the duration of among other indications. Aside from the inconvenience
surgery and the ease with which a single miniplate to the patient, there was a cost to additional interven-
tion. The advantage of placing hardware at the superior
was applied when compared with the internal wire
border is that it is more readily retrievable in the clinic
and double miniplate groups. A single miniplate, from
setting. The group treated with 2 miniplates more com-
incision to last suture, could be placed in an average
monly required a general anesthetic in the operating
of 23.5 minutes, and its placement was never rated as
room to retrieve the hardware or treat the infection.
“difficult” by the surgeons. In fact, it was rated “some
This adds substantially to the cost of treating the com-
difficulty” in only 5 cases. All other cases were rated
plication.
as “simple.” Two miniplates took an average of 37
In summary, the use of a single miniplate was asso-
minutes to apply and was rated “difficult” in 9 cases
ciated with fewer complications than if 2 plates were
and “somewhat difficult” in 27 cases—as many cases
used or if an interosseous wire and MMF were em-
as were rated “simple.” Placement of the second plate ployed. It was also found to be the easiest internal
at the inferior border is a more difficult task and fixation scheme to master. Fortunately, the technique
requires more experience to become facile. This un- that offers the best results is also that which is the
doubtedly comes from the need to use a trochar to simplest to learn.
apply the plate at the lower border, where access and
visibility are much more limited. Without a clear ben-
efit to the second plate, taking the time and suffering
References
the aggravation of placing it can be questioned. There 1. Wagner WF, Neal DC, Alpert B: Morbidity associated with
extraoral open reduction of mandibular fractures. J Oral Surg
are also additional costs incurred using a second bone 37:97, 1979
plate, including not only the cost of the plate and 4 2. James RB, Fredrickson C, Kent JN: Prospective study of man-
more screws but the additional time to place it. dibular fractures. J Oral Surg 39:275, 1981
3. Chuong R, Donoff RB, Guralnick WC: A retrospective analysis
The finding that a single miniplate outperforms 2 of 327 mandibular fractures. J Oral Maxillofac Surg 41:305,
plates defies logic because conventional wisdom 1983
would indicate that more stable fixation should pro- 4. Iizuka T, Lindqvist C, Hallikainen D, et al: Infection after rigid
internal fixation of mandibular fractures. A clinical and radio-
vide fewer complications. All biomechanical tests per- logic study. J Oral Maxillofac Surg 49:585, 1991
formed to date indicate that 2 plates are more stable 5. Passeri LA, Ellis E, Sinn DP: Complications of non-rigid fixation of
mandibular angle fractures. J Oral Maxillofac Surg 51:382, 1993
than 1.17,18,48-52 However, the results of this investi- 6. Spiessl B (ed): New Concepts in Maxillofacial Bone Surgery.
gation corroborate the findings of previous prospec- Berlin, Springer-Verlag, 1976
tive studies38-41 and the many retrospective noncom- 7. Spiessl B: Internal Fixation of the Mandible. New York, Springer-
Verlag, 1989
parative studies14,16,25,29,31-37 that have found that the 8. Luhr HG: Compression plate osteosynthesis through the Luhr
complication rate is as low or lower using a single System, in Krüger E, Schilli W (eds): Oral and Maxillofacial
miniplate to treat angle fractures when compared with Traumatology, Volume 1. Chicago, Quintessence, 1982
9. Champy M, Loddé JP, Schmitt R, et al: Mandibular osteosyn-
using 2 miniplates. This indicates that biomechanics, thesis by miniature screwed plates via a buccal approach.
although important, is not the only factor to be consid- Max-Fac Surg J:6:14-21, 1978
2754 ISOLATED FRACTURES OF THE MNDIBULAR ANGLE

10. Ellis E, Karas N: Treatment of mandibular angle fractures using 31. Ellis E, Ghali GE: Lag screw fixation of mandibular angle frac-
two mini-dynamic compression plates. J Oral Maxillofac Surg tures. J Oral Maxillofac Surg 49:234, 1991
50:958, 1992 32. Ellis E: Lag screw fixation of mandibular fractures. J Cranio
11. Ellis E: Treatment of mandibular angle fractures using the AO Maxillofac Trauma 3:16, 1997
reconstruction plate. J Oral Maxillofac Surg 51:250, 1993 33. Ellis E: Treatment methods for fractures of the mandibular
12. Ellis E, Sinn DP: Treatment of mandibular angle fractures using angle. J Cranio Maxillofac Trauma 2:28, 1996
two 2.4 mm dynamic compression plates. J Oral Maxillofac 34. Potter J, Ellis E: Treatment of mandibular angle fractures with
Surg 51:969, 1993 a malleable non-compression miniplate. J Oral Maxillofac Surg
13. Ellis E, Walker L: Treatment of mandibular angle fractures using 57:288, 1999
two noncompression miniplates. J Oral Maxillofac Surg 52: 35. Ellis E: Treatment methods for fractures of the mandibular
1032, 1994 angle. Int J Oral Maxillofac Surg 28:243, 1999
14. Ellis E, Walker LR: Treatment of mandibular angle fractures 36. Iizuka T, Lindqvist C: Rigid internal fixation of fractures in the
using one noncompression miniplate. J Oral Maxillofac Surg angular region of the mandible: An analysis of factors contributing
54:864, 1996 to different complications. Plast Reconstr Surg 91:265, 1993
15. Wald RM, Abemayor E, Zemplenyi J, et al: The transoral treatment 37. Valentino J, Levy FE, Marentette LJ: Intraoral monocortical
of mandibular fractures using noncompression miniplates: A pro- miniplating of mandible fractures. Arch Otolaryngol Head Neck
spective study. Ann Plast Surg 20:409, 1988 Surg 120:605, 1994
16. Levy FE, Smith RW, Odland RM, et al: Monocortical miniplate 38. Ehrenfeld M, Roser M, Hagenmaier C, et al: [Treatment of
fixation of mandibular fractures. Arch Otolaryngol Head Neck mandibular fractures with different fixation techniques–results
Surg 117:149, 1991 of a prospective fracture study]. Fortschr Kiefer Gesichtschir
17. Choi BH, Kim KN, Kang HS: Clinical and in vitro evaluation of 41:67, 1996
mandibular angle fracture fixation with two-miniplate system. 39. Niederhagen B, Anke S, Hultenschmidt D, et al: [AO and
J Oral Surg 79:692, 1995 miniplate osteosynthesis of the mandible in an 8-year compar-
18. Choi BH, Yoo JH, Kim KN, et al: Stability testing of a two-miniplate ison]. Fortschr Kiefer Gesichtschir 41:58, 1996
fixation technique for mandibular angle fractures. An in vitro 40. Schierle HP, Schmelzeisen R, Rahn B, et al: One- or two-plate
study. J Craniomaxillofac Surg 23:122, 1995 fixation of mandibular angle fractures? J Craniomaxillofac Surg
19. Fox AJ, Kellman RM: Mandibular angle fractures: Two- 25:162, 1997
miniplate fixation and complications. Arch Facial Plast Surg 41. Siddiqui A, Markose G, Moos KF, et al: One miniplate versus two
5:464, 2003
in the management of mandibular angle fractures: A prospective
20. Michelet FX, Deymes J, Dessus B: Osteosynthesis with minia-
randomised study. Br J Oral Maxillofac Surg 45:223, 2007
turized screwed plates in maxillofacial surgery. J Max-Fac Surg
42. Ellis E: Rigid versus non-rigid fixation, in Miloro M, Ghali G,
1:79-84, 1973
Larsen P, Waite P (eds): Peterson’s Principles of Oral and
21. Gerlach KL, Pape HD: Prinzip und Indikation der miniplatten-
Maxillofacial Surgery Ontario [chapter 20], Canada, BC Decker,
ostéosynthèse. Dtsch Zahnaerztl Z 35:346, 1980
2004
22. Pape HD, Gerlach KL: Le traitement des fractures des maxil-
43. Ellis E: Management of fractures through the angle of the
laires chez l’enfant et l’adolescent. Rev Stomatol Chir Maxillo-
fac 81:280, 1980 mandible, in Current Controversies in Maxillofacial Trauma,
23. Gerlach KL, Pape HD, Tuncer M: Funktionsanalytische Unter- Oral and Maxillofacail Surgery Clinics of North America. 21:
suchungen nach der miniplattenosteosynthese von unterkief- 163-174, 2004
erfrakturen. Dtsch Z Mund Kiefer Gesichts Chir 6:57, 1982 44. Ellis E, Miles BA: Fractures of the mandible: a technical per-
24. Pape HD, Herzog M, Gerlach KL: Der Wandel der unterkeifer- spective. Plast Reconstr Surg 120:76S-89S, 2007
frakturversorgung von 1950 bis 1980 am beispeil der Kglner 45. Chin R, Lee BY: Principles and Practice of Clinical Trial Medi-
Klinik. Dtsch Zahnarztl Z 38:301, 1983 cine. Amsterdam, Academic Press, 2008
25. Cawood JI: Small plate osteosynthesis of mandibular fractures. 46. Assael L: Evalutaion of rigid internal fixation of mandible frac-
Br J Oral Maxillofac Surg 23:77, 1985 tures performed in the teaching laboratory. J Oral Maxillofac
26. Ewers R, Härle F: Biomechanics of the midface and mandibular Surg 51:1315, 1993
fractures: Is a stable fixation necessary? in Hjørting-Hansen E 47. Kearns GJ, Perrott DH, Kaban LB: Rigid fixation of mandibular
(ed): Oral and Maxillofacial Surgery: Proceedings from the 8th fractures: Does operator experience reduce complications?
International Conference on Oral and Maxillofacial Surgery J Oral Maxillofac Surg 52:226, 1994
Quintessence, 1985 48. Dichard A, Klotch DW: Testing biomechanical strength of repairs
27. Ewers R, Härle F: Experimental and clinical results of new for the mandibular angle fracture. Laryngoscope 104:201, 1994
advances in the treatment of facial trauma. Plast Reconstr Surg 49. Fedok FG, Van Kooten DW, DeJoseph L, et al: Plating tech-
75:25, 1985 niques and plate orientation in repair of mandibular angle
28. Feller K-U, Schneider M, Hlawitschka M, et al: Analysis of fractures: An in vitro study. Laryngoscope 108:1218, 1998
complications in fractures of the mandibular angle—A study 50. Kroon FHM, Mathisson M, Cordey JR, et al: The use of
with finite element computation and evaluation of data of 277 miniplates in mandibular fractures. J Craniomaxillofac Surg
patients. J Cranio-Maxillofac Surg 31:290, 2003 19:199, 1991
29. Barry CP, Kearns GJ: Superior border plating technique in the 51. Schierle HP, Schmelzeisen R, Rahn B, et al: One- or two-plate
management of isolated mandibular angle fractures: A Retro- fixation of mandibular angle fractures? J Craniomaxillofac Surg
spective Study of 50 consecutive patients. J Oral Maxillofac 25:162, 1997
Surg 65:1544, 2007 52. Shetty V, McBrearty D, Fourney M, et al: Fracture line stability
30. Leach J, Truelson J: Traditional methods vs rigid internal fixa- as a function of the internal fixation system: An in vitro com-
tion of mandible fractures. Arch Otolaryngol Head Neck Surg parison using a mandibular angle fracture model. J Oral Maxil-
121:750, 1995 lofac Surg 53:791, 1995