Purpose: Treating comminuted mandibular fractures remains a challenge. In this study, we used
titanium mesh to treat comminuted mandibular fractures.
Materials and Methods: Nine patients with traumatically comminuted mandibular fractures who
received open reduction and internal stable fixation with titanium mesh were retrospectively reviewed.
Open reduction–internal stable fixation was performed 7 to 10 days after primary debridement of the facial
trauma. After the fractured mandible and the displaced fragments were reduced, the titanium mesh was
reshaped according to the morphology of the mandible, and the reduced bone fragments were fixed
with the reshaped titanium mesh and screws. Then, the surgical effects were evaluated during routine
follow-up.
Results: Most of the displaced fragments were reserved and exhibited a favorable shaping ability in
restoring the morphology of the mandible during surgery. Q3 No intraoperative complications were encountered. In addition, all patients were infection free, with no obvious resorption in the fixed fragments after
surgery. The mandible also exhibited favorable morphology and offered sufficient bone mass for dental
implantation or a denture prosthesis.
Conclusions: We conclude that titanium mesh shaping and fixation can effectively treat comminuted
mandibular fractures with little bone fragment loss, little soft tissue exposure, a low infection rate, and
favorable mandibular morphology.
Although there are a considerable number of treatment methods for comminuted mandibular fractures,
treating such fractures remains a challenge because
of the high infection rate, unsatisfactory mandibular
shape, and loss of bone fragments. Treatment
methods include closed reduction; external pin fixation; internal wire fixation; and open reduction and
internal stable fixation (ORIF) using miniplates,
reconstruction plates, or screws.
1-3
It was
previously believed that open surgery impairs the
precarious vascularity to the bone fragments, which
results in sequestration and infection, and that
comminuted mandibular fractures should be treated
in a closed manner to prevent the stripping of the
blood supply from the fragments.
1,2
However,
Kazanjian and many other researchers stated that
stabilization of the fragments was the most
important factor in obtaining an osseous union of
comminuted fragments, rather than the initial loss
of bone, and ORIF with plates or screws has thus become a mainstream method for treating
comminuted fractures.
1
Q5
Two principles in bone fracture fixation, that is, the
need to support full functional loads and the need to
retain the absolute stability of the fracture construct,
play crucial roles in sound bone healing and maintaining a low rate of infection. However, the load-sharing
osteosynthesis between the implant and bone cannot
be achieved when using limited plates or screws in
comminuted fractures. Furthermore, discouraging reports from past experiences with ORIF using wires,
mini-plates, or even reconstruction plates have been
associated with infection, which has resulted in substantial bone loss and associated morbidity.
3,4
Q6 Q7
Although there is a lack of extensive reports on
comminuted mandibular fractures, previous studies
have reported some surgical complications that
occurred after ORIF of comminuted mandibular
fractures. Iizuka et al
5
reported an infection rate of
6.1% when using the AO/ASIF principle of rigid fixation. Kuriakose et al
6
compared ORIF using 2.7-mm
AO/ASIF reconstruction plates with miniplates, and a
substantial difference in the incidence of infection between the 2 groups was seen (30% with miniplates vs
14.3% with reconstruction plates). Scolozzi and
Richter
7
reported a 3% infection rate when 2.4-mm
AO titanium reconstruction plates were applied to
treat severe mandibular fractures. In addition, the
preservation of bone fragments and the restoration
of mandibular shape were difficult to achieve by using
plates or screws.
7
Q8
Comminuted mandibular fractures have been
treated in our department using a number of techniques, including closed reduction and ORIF. Over
the past 5 years, we also have treated bone defects using autologous iliac bone with titanium mesh, and we
have used titanium mesh shaping and fixation to treat
comminuted mandibular fractures. To our surprise,
good treatment results have been shown, including a
low infection rate, favorable mandibular morphology,
little soft tissue exposure, and little loss of bone
fragments. The purpose of this study was to retrospectively evaluate our experience in treating
comminuted mandibular fractures using titanium mesh.
Materials and Methods
PATIENTS
This study was performed in the department of oral
and craniomaxillofacial surgery at our hospital. The
registries of patients with traumatically comminuted
mandibular fractures receiving ORIF at our hospital
during the past 4 years (2011 through 2014) were
retrospectively reviewed. Informed consent to participate in this study was obtained from each patient,
and all patients who appear in the figures gave full
permission for their images to be used in this publication. The study protocol followed the guidelines of the
Declaration of Helsinki and was approved by the
Ethics Committee of Shanghai Ninth People’s Hospital,
Shanghai Jiaotong University School of Medicine. All of
the experiments described in this article were performed in accordance with the guidelines and regulations issued by the Ethics Committee of Shanghai
Ninth People’s Hospital, Shanghai Jiaotong University
School of Medicine. The medical charts or records of
the enrolled patients were retrieved and subjected to
further review to obtain information regarding patient
demographic data and clinical features.
The definitive diagnosis of a traumatically comminuted mandibular fracture was made largely based
on clinical examination findings, radiographic features, and computed tomography (CT) examination
findings, and comminuted fractures were defined as
fractures with more than 2 free bone fragments.
Nine patients with traumatically comminuted mandibular fractures who received ORIF with titanium mesh
were included in this study (Fig 1). The patient group
comprised 8 male patients and 1 female patient aged
between 13 and 41 years (mean, 27.448.26 years).
Basic information about these patients is shown in
Table 1. Use of titanium mesh and other alternative
methods, including ORIF using reconstruction plates
and miniplates, was presented to all the patients preoperatively. The patients then made their own decisions based on full disclosure of the advantages and
disadvantages of the techniques.
SURGICAL PROCEDURE
The ORIF surgical procedure for comminuted
mandibular fractures was performed 7 to 10 days after
primary debridement. Primary debridement aimed to
stop the bleeding, close the wound in the oral cavity,
clean the area around the fracture regions, and maintain the occlusal relationship using intermaxillary fixation (IMF) under general or local anesthesia. If a
combined maxillary fracture was present, we also performed ORIF for the maxillary fracture during the primary operation to obtain a favorable occlusal relationship (Fig 2). All ORIF surgical procedures were
performed with patients under general endotracheal
anesthesia. The procedure was initiated by making
an extraoral submandibular incision or an incision
along the primary extraoral wound to expose the fractured mandible and fragments and to avoid contact
with the intraoral bacterial conditions. Then, the fractured mandible and the displaced fragments were
reduced. Subsequently, the titanium mesh, with a
thickness of 0.6 mm (Stryker, Kalamazoo, MI), was reshaped according to the morphology of the mandible,
and the reduced bone fragments were fixed with the
reshaped titanium mesh and screws. For some patients, the larger mandibular segments were fixed
with miniplates (Fig 3). During surgery, the restoration
of primary occlusion is a standard procedure for bone
reduction. Finally, the extraoral wound was sutured
layer by layer with No. 3-0 and 5-0 absorbable sutures
and No. 6-0 polyglactin 910 sutures (Vicryl; Ethicon,
Somerville, NJ). Q9 Antibiotic prophylaxis with cefotiam
was used and maintained for all patients for 3 days after
surgery. All patients required IMF for 7 to 10 days after surgery.
POSTOPERATIVE EVALUATION
The clinical examination and craniofacial CT data
from the 9 patients were retrospectively analyzed at
routine follow-up intervals of 3, 6, and 12 months.
The wound condition, resorption condition of the
bone fragments, mandibular morphology, and mandibular function were chosen to evaluate the surgical effects.
Results
Detailed information about the patients is shown in
Table 1. There were 6 patients with comminuted
mandibular fractures in the symphyseal region and 3
patients with comminuted mandibular fractures in
both the mandible body and symphyseal region. Four
patients simultaneously had comminuted mandibular fractures and condylar fractures, and 1 patient simultaneously had comminuted mandibular fractures and
zygomatic-maxillary fractures. Complicated condylar
fractures were treated with ORIF using miniplates or
long screws, and zygomatic-maxillary fractures
received ORIF using miniplates. Q10
During surgery, the extraoral incision offered a clean
approach for the reduction and fixation of the fractured mandible. Most of the displaced fragments
were preserved and fixed, and no autogenous or heterogeneous bone was needed to fill the defect. In addition, the titanium mesh exhibited good shaping ability,
and the favorable morphology of the mandible was
restored during surgery (Fig 3). No intraoperative complications were encountered. The operation time from
the incision to the fixation of the displaced fragment of
the fractured mandible (including fixation) was
454.52 minutes.
The postoperative mandibular morphology and function were evaluated by clinical examination and CT
exami