Edward Ellis

An Analysis of 2,067 cases of zygomatico-orbital fracture

A ten-year review of 2,067 cases of zygomatico-orbital fractures is presented. The age and sex distribution, anatomical types of fractures, associated maxillofacial and nonmaxillofacial trauma, and causes of the injuries are described. The majority of fractures were sustained by males and resulted from trauma inflicted in altercations. The most common associated facial fractures were mandibular; the most common associated nonmaxillofacial trauma was extremity fractures. Motorcycle accidents caused the most significant amount of associated trauma, followed by motor vehicle accidents in which no seat restraint was used by the victim. Treatment, when indicated, consisted of elevation via a temporal approach followed by fixation where necessary. The fixation methods used are presented and discussed.

Treatment methods for fractures of the mandibular angle

Fractures of the mandibular angle are plagued with the highest rate of complication of all mandibular fractures. Over the past 10 years, various forms of treatment for these fractures were performed on an indigent inner city population. Treatment included: 1) closed reduction or intraoral open reduction and non-rigid fixation; 2) extraoral open reduction and internal fixation with an AO/ASIF reconstruction bone plate; 3) intraoral open reduction and internal fixation using a solitary lag screw; 4) intraoral open reduction and internal fixation using two 2.0 mm mini-dynamic compression plates; 5) intraoral open reduction and internal fixation using two 2.4 mm mandibular dynamic compression plates; 6) intraoral open reduction and internal fixation using two non-compression miniplates; 7) intraoral open reduction and internal fixation using a single non-compression miniplate; and 8) intraoral open reduction and internal fixation using a single malleable non-compression miniplate. This paper reviews the results of those modes of treatment when used for the same patient population at one hospital. Results of treatment show that, in this patient population, the use of either an extraoral open reduction and internal fixation with the AO/ASIF reconstruction plate or intraoral open reduction and internal fixation, using a single miniplate, are associated with the fewest complications.

Treatment of mandibular angle fractures using one noncompression miniplate

PURPOSE This study evaluated the results in patients treated for fractures of the mandibular angle with a single miniplate. PATIENTS AND METHODS Eighty-one patients with fractures of the mandibular angle were treated by open reduction and internal fixation using one noncompression miniplate with 2.0-mm self-threading screws placed through a transoral incision. No patient was placed into postsurgical maxillomandibular fixation. They were prospectively studied for complications. RESULTS Thirteen patients with angle fractures (16%) experienced complications requiring secondary surgical intervention. Most of the complications (n = 11), however, were minor and could be treated in the office. Most commonly, intraoral incision and drainage and later removal of the bone plate were required. All patients with minor complications had clinical union. Only two complications required hospitalization for intravenous antibiotics and further surgery. One of these patients had a fibrous union requiring a bone graft. CONCLUSIONS The use of a single miniplate for fractures of the angle of the mandible is a simple, reliable technique with a relatively small number of major complications.

Occlusal results after open or closed treatment of fractures of the mandibular condylar process

PURPOSE This study compared the occlusal relationships after open or closed treatment for fractures of the mandibular condylar process. PATIENTS AND METHODS A total of 137 patients with unilateral fractures of the mandibular condylar process (neck or subcondylar), 77 treated closed and 65 treated open, were included in this study. Standardized occlusal photographs obtained at several postsurgical time intervals were examined and scored by a surgeon and an orthodontist. Standard statistical methods were used to assess differences between groups. RESULTS Patients treated by closed techniques had a significantly greater percentage of malocclusion compared with patients treated by open reduction, in spite of the fact that the initial displacement of the fractures was greater in patients treated by open reduction. CONCLUSIONS Based on this study, more consistent occlusal results can be expected when fractures of the mandibular condylar process are treated by open reduction.

Bite forces in patients treated for mandibular angle fractures: Implications for fixation recommendations

Voluntary bite forces were recorded at varying periods in 35 males treated with rigid internal fixation for fractures of the mandibular angle. Bite forces were also obtained in 29 male controls for comparison. It was found that molar bite forces in patients were significantly less than in controls for several weeks after surgery. Further, molar bite forces on the side of the fracture were significantly less than on the nonfractured side. The results of this study indicate that recommendations for the amount of fixation required for a given fracture may be reduced.

Mandibular motion after closed and open treatment of unilateral mandibular condylar process fractures

PURPOSE This study compared mandibular and condylar mobility after open or closed treatment for fractures of the mandibular condylar process. PATIENTS AND METHODS One hundred thirty-six patients (111 male, 25 female), 74 treated by closed and 62 by open methods, were included in this study. They underwent testing of mandibular and condyle mobility at 6 weeks, 6 months, and 1, 2, and 3 years postsurgery. A jaw-tracking device was used to assess mandibular motion. Radiographs that were traced and digitized were used to assess condylar displacement and condylar mobility. Standard statistical methods were used to assess differences between groups. RESULTS Patients treated by open reduction had significantly greater initial displacement of their condylar processes than did the group treated closed. Immediately after treatment and uprighting of the condyles in the open treatment group, patients treated closed had significantly more displacement. At 6 weeks, patients treated closed had some measures of mandibular mobility that were significantly greater than those in patients treated by open reduction. However, after the 6-week period there were minimal differences in mandibular mobility between groups. At 6 weeks, patients treated by open reduction had significantly greater vertical mobility of the condyle than patients treated closed despite less mouth opening. After the 6-week period, patients treated by open reduction continued to have greater condylar mobility on the fractured side than did patients treated by closed methods. No measures of postsurgical displacement correlated with mobility measures in patients treated by open reduction. However, several measures of mandibular displacement correlated with measures of mobility in patients treated closed, indicating that the more displaced the condylar process, the more limited the mobility of the mandible. CONCLUSIONS Based on this study, patients treated for fractures of the mandibular condylar process by open reduction had somewhat greater condylar mobility than patients treated closed, even though the former group had more severely displaced fractures before surgery. Therefore, open reduction may produce functional benefits to patients with severely displaced condylar process fractures.

Histologic examination of the temporomandibular joint after mandibular advancement with and without rigid fixation: an experimental investigation in adult Macaca mulatta.

This study evaluated the histologic response of the temporomandibular joint (TMJ) following mandibular advancement using rigid and nonrigid fixation in monkeys. Twelve adult female rhesus monkeys underwent sagittal ramus osteotomies with advancement. Six of them were placed into maxillomandibular fixation (MMF); six underwent bicortical bone-screw fixation without MMF. Changes in condylar position were quantified using lateral cephalograms with the aid of bone markers. The animals were killed at 6 weeks and the TMJs were prepared for histologic analysis. Three measures of condylar cartilage thickness were obtained for each animal and were correlated to changes in position of the condyle. Animals who underwent MMF showed a tendency for anterior movement of the condyles; animals who underwent rigid fixation showed a tendency for posterior condylar position. Thicker cartilage layers were found in the MMF animals. Animals who had posterior displacement of the condyles showed evidence of resorption of the posterior surface of the condyle and anterior surface of the postglenoid spine. There was a significant correlation between a change in the horizontal position of the condyle and the thickness of the posterior aspect of the condylar cartilage. The results of this study indicate that alterations in condylar position may induce remodeling changes within the TMJ.

Treatment of mandibular angle fractures using two noncompression miniplates

PURPOSE To evaluate treatment with two 2.0-mm noncompression miniplates for patients with angle fractures. PATIENTS AND METHODS Sixty-seven consecutive patients with 69 fractures of the mandibular angle were treated by open reduction and internal fixation using two noncompression miniplates and 2.0-mm self-threading screws placed through a transoral incision with transbuccal trochar instrumentation. No patient was placed into postsurgical maxillomandibular fixation or elastics. RESULTS Overall, 19 fractures (28%) experienced complications requiring secondary surgical intervention. Most of the complications were postoperative infections requiring surgical drainage (n = 17) and subsequent hardware removal (n = 16). Of the 17 infected fractures, 11 were healed at the time of hardware removal and required no further treatment. Five were still mobile and required a period of maxillomandibular fixation for healing. One of the fractures did not heal and required bone grafting. CONCLUSION The use of two noncompression miniplates was found to be relatively easy, but resulted in an unacceptable rate of infection in our patient population when used for treatment of fractures of the mandibular angle.

Treatment of mandibular angle fractures using two mini dynamic compression plates

Sixty-five consecutive patients with fractures of the mandibular angle were treated by open reduction and internal fixation using two dynamic compression plates placed through a transoral incision using transbuccal trochar instrumentation and 2.4-mm screws. In the first 20 cases, the screws were inserted without tapping the drill holes. In the remaining 45 cases, the drill holes were tapped. No patient was placed into postsurgical maxillomandibular fixation or training elastics. Overall, 21 fractures (32%) developed infections requiring secondary surgical intervention. The infection rate was higher in those fractures where the holes were not tapped (40%) than those cases when the holes were tapped (29%). Of the 21 fractures that required hardware removal, 9 fractures were healed and required no further treatment; 12 had no firm bony union and required postsurgical maxillomandibular fixation. Only one case resulted in a malunion with resulting malocclusion. The use of two dynamic compression plates was found to be relatively easy, but resulted in an unacceptable rate of infection.

Components of adult Class III open-bite malocclusion☆

In an effort to identify the frequency and differences in the dental and skeletal components of a large sample of adults with Class III malocclusion, with and without open bite, 176 subjects, one half of whom had an anterior open bite, were evaluated. These subjects were chosen by looking at the lateral cephalometric radiographs that were taken of 302 adults (128 men and 174 women) who exhibited at least an end-to-end Class III molar and canine relationship. The dental overbite was calculated for all subjects, and those with a negative overbite were placed in the open-bite (OB) group. Those with a positive overbite were placed in the non-open-bite (non-OB) group. The dental overbite was the only criterion used to define the open-bite and non-open-bite groups. The open-bite subjects were paired with a non-open-bite subject by sex, presence of presurgical orthodontic treatment, and anterior cranial base length. Eighty-eight subjects in each group (43 men and 45 women) were obtained. Various measures of craniofacial structure were calculated and analyzed by comparing the OB and non-OB groups with the paired t test. The areas that showed significant differences (p less than 0.05) between the OB and non-OB groups were as follows: the posterior maxilla exhibited vertical excess in the OB group; the maxillary occlusal plane was less steep in the OB group; the mandibular occlusal plane was more steep in the OB group; the gonial angle was higher in the OB group; the mandibular plane angle was higher in the OB group; the mandibular ramus was positioned in a more downward and backward location in the OB group; the total anterior facial height and lower facial height were increased in the OB group; the vertical height of the anterior maxilla was increased in the OB group; and the mandible was less protrusive in the OB group. No significant intergroup differences were noted in the cranial base, the anteroposterior position of the maxilla or the upper and lower incisors, the palatal plane, posterior facial height, mandibular ramus height, or mandibular body height. The results of this analysis indicate that the average Class III open-bite malocclusion is characterized by aberrations in both the maxilla and the mandible. Surgical therapy may, therefore, require intervention in both jaws to correct this deformity successfully.