Compare the Efficacy of Open Reduction and Internal Fixation of Mandibular Fractures With and Without Use of Intra-Operative Inter-Maxillary Fixation (2024)

Abstract

Mandible fractures are regularly encountered by maxillofacial surgeons and various treatment protocols are available for the management of these fractures. The aim of study compares the efficacy of open reduction and internal fixation of mandibular fractures with and without use of intra-operative inter-maxillary fixation. Twenty patients between age group ranging l8–65years who reported with single mandibular fracture in Dental college in India, during Oct 2012–March 2015 were the study subjects. These patients were divided into two groups. In one group fracture reduction was done by using inter-maxillary fixation and miniplate fixation was done. In other group fracture reduction was done manually and then fractured fragments were held in position by the assistant and miniplate fixation was done. Post-operatively patients were evaluated for occlusion, bone alignment and soft tissue/hard tissue infection at 1st, 4th, 8th, 12th weeks in both the groups. Statistics done by using Spearman’s Rank correlation coefficient and Mann–Whitney U test. It was observed thatthere was no statistically significant difference seen in both the groups in terms of post-operative occlusion, radiological alignment and soft/hard tissue infection. Statistically significant difference was seen when the mean operating time was compared. The Group A showed mean difference of 35.50min more time than Group B. The results of our study suggested that, use of intra-operative IMF does not show any advantages in terms of post-operative occlusion, bone alignment and soft/hard tissue infection. We have concluded from the study that the increased intra-operative time for the placement of IMF increases the cost of the surgery in regard to equipment and theatre time. There is no benefit in terms of radiographic and clinical outcome. Hence use of intra-operative IMF can be avoided for ORIF of single mandibular fracture.

Keywords: IMF, Miniplates, Operating time

Introduction

Maxillofacial trauma accounts for 15–58% of all injuries [1]. Mandibuar fracture incidence is about 38% of all maxillofacial fractures. The management of mandibular fracture is different as compared to long bones because of presence of teeth. The aim of the treatment is not only to achieve the normal anatomic form but also the occlusion, function & esthetics [2]. For many years intermaxillary fixation (IMF) was used for closed reduction of mandibular fracture. Intermaxillary fixation can be achieved by archbar fixation, eyelet wiring, self drilling IMF screws, cast metal splints and self tapping IMF screws. But it is common finding that patients treated with IMF alone have functional but not premorbid occlusion postoperatively and fractures don’t have anatomic reduction when evaluated radiographically [3, 4]. In past few decades the plate osteosynthesis has gained the popularity as a method of fixation of the facial fractures, as it provides re-establishment of patient’s normal occlusion and proper anatomic reduction of the bone [4]. Studies done in past emphasizes that IMF is necessary to achieve normal occlusion, most of the surgeons still use it as a method of reduction of fractured fragments during the intra-operative period [5, 6]. The Aim of the study is to compare the efficacy of open reduction and internal fixation of mandibular fractures with and without use of intra-operative intermaxillary fixation.

Materials and Methods

Source of data: Twenty patients between the age group of 18–65years who reported with single fracture of the mandible, in the Department of Oral and Maxillofacial Surgery of Dental college in India, during Oct 2012–March 2015diagnosed on the basis of clinical and radiographic examination are included in the study. Inclusion criteria: Patient with displaced or minimally displaced unilateral Symphysis and Parasymphysis mandible fracture which are simple or compound in nature require open reduction and internal fixation Exclusion criteria: Patients with multiple maxillofacial fracture, systemic diseases, dentoalveolar trauma with mandibular fracture, mandible angle, body and condylar fracture are excluded from the study. A standard Performa was used to collect the necessary information regarding each case after inclusion. The patients were informed about the study and necessary consent was taken from concerned personnel. The patients after inclusion were randomly divided into Groups: Group A:10 Patients who underwent ORIF of mandibular fracture with intra-operative IMF. Group B: 10 Patients who underwent ORIF of mandibular fracture without intra-operative IMF. Patients were evaluated pre-operatively. intra-operatively and postoperatively for various parameters. Post-operative clinical evaluation was done after 1st week, 4th week, 8th week and 12th week. Post operative occlusal evaluation was done after 1st and 12th week. The statistics analysis was done using Spearman’s Rank correlation coefficient and Mann–Whitney U test. Preoperative Assessment includes: Clinical assessment of Occlusion: Grossly altered, slightly altered and normal and Radiological Assessment by taking OPG.

Result

Discussion

The incidence rate of mandibular raclure in maxillo-facial trauma is roughly 38%. As mandibular fracture effects not only the alignment of bone but also the function, occlusion and the esthetics of an individual, the treatment aims to correct all these discrepancies [7, 8]. To achieve the normal occlusion and function, the fracture segments needs to be aligned in a normal anatomical position. This is achieved when fracture segments arc reduced and fixed properly. The anatomic reduction of the fractured segments can be achieved either by intermaxillary fixation or manual reduction [8]. IMF can be done by Erich arch bars, eyelet wiring, self drilling IMF screws, cast metal splints or self tapping IMF screws [9]. For manual reduction the surgeon needs a skilled assistant to hold the fracture segments in the position. Use of reduction forceps also provides precise anatomical reduction but its use seems to be difficult [10]. However there are some disadvantages of the IMF, such as increased intra-operative time, increased cost of the surgery & chances of injury to the surgeon and the operating team [11]. Hence we did a comparative study of ORIF of single mandibular fracture with and without intra-operative IMF, to find out any potential advantages of intra-operative IMF.

In our study The use of intra-operative IMF increases operative time. It was noted in other studies that the mean operating time for ORIF of mandibular angle fracture with IMF was 98.5min, and without IMF was 40.2min [11, 12]. In our study, the average time required for ORIF of mandibular fracture of with IMF (Group A) was 85.50min while in Group B, the mean time was 50min. Both of these groups showed statistically significant (P = 0.001) difference when compared. Fordyce stated that as the use of IMF increases procedure time, the cost of manufacturing and applying arch bars, increased length of general anesthesia, personnel and outpatient time required to remove this metal work post-operatively also add to the total cost of the treatment [12–14]. In our study there were no difficulties seen in the reduction and fixation of the fractured segments in both the groups. Also there were no difficulties in the adaptation of the hardware in both the groups.

Disturbance in the occlusion may occur as a result of improperly reduced or fixed fractures. George Oimitrouli in his study did occlusal evaluation 6weeks post-operatively & he noticed the insignificant difference in both the groups. Few other studies also noted statistically insignificant difference of occlusal disturbance in both these groups [15, 16]. In our study, occlusal evaluation was done after 1st and 12th week. First week post-operatively 50% of patients in Group A and 50% of patients in Group B complained about the disturbed occlusion but it resolved later and after 12weeks patients were satisfactory about their occlusion. When we statistically compared both the groups, there was no significant difference. This suggests that intra-operative IMF does not provide any additional benefit with regard to post-operative occlusion. In our study post-operative radiograph (OPG) was taken at 1st and 12th post-operative week. Precise anatomical reduction of fractured segments was seen in both the groups. When these groups were compared statically insignificant difference was seen. This suggests that intra-operative IMF does not provide any additional benefit with regard to maintenance of fracture reduction. It is noted in various studies that there is a minimal soft tissue infection incidence (0–6%) in all the case and they all found clinical and statically insignificant [17, 18]. In our study patients were recalled on 1st, 4th, 8th & 12th week post-operatively for clinical evaluation. We did not note any soft/hard infection at the surgical site. Intra-operative IMF significantly increases intra-operative time, as evident from our study. Also there are more chances of injury to the surgeon and operating team by the wires used for IMF, as suggested by various authors. It does not provide any additional benefit with respect to reduction of fragment as evident from our study.

Conclusion

This study was done to compare the treatment outcomes of open reduction and internal fixation of mandibular fracture with and without intra-operative intermaxillary fixation. Based on the observations in 20 patients who were divided into 2 groups, following conclusions were drawn-

1. There was a significant difference in the total procedure time between both these groups. The use of intra-operative intermaxillary fixation resulted in the increased total operating time and so the increased operation cost.

2. Though it is suggested that IMF aids the reduction of fractured segments, the intra-operative difficulty in reduction and fixation was same in both the groups.

3. The occlusal outcomes were same in both the groups when they were evaluated post-operatively.

4. There was no difference in both the groups when they were assessed radiographically (OPG) for the post-operative bone alignment.

5. Wound healing outcomes were almost similar in both the groups in early and late post-operative period.

In the conclusion, the use of intra-operative IMF increases the cost regard to both equipment and theatre time. There is no benefit in terms of radiographic and clinical outcome. Hence use of intra-operative IMF can be avoided in the ORIF of displaced or minimally displaced unilateral Symphysis and Parasymphysis mandible fracture.

Declarations

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