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Treatment of bilateral fracture in severely displaced atrophic mandible
LORENZZO DE ANGELI CESCONETTO 1 | ANDRÉ VÍTOR ALVES ARAÚJO 1,2 | ANTONIO DIONIZIO ALBUQUERQUE NETO 1 | DANIEL ASSUNÇÃO CERQUEIRA 1,2 | ANTONIO AUGUSTO CAMPANHA 1
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ABSTRACT
Introduction: The mandibular atrophy leads to a decrease in bone mass, which makes the bone more vulnerable to fracture. Numerous methods are proposed for the treatment of this condition. The use of 2.4 locking plates system, is the most common nowadays. Case report: A 79-year-old female patient, presenting a fracture in the bilateral mandibular body region, undergone surgical reduction and rigid internal fixation of the fracture, through an extraoral approach with a 2.4 locking plate system. Conclusion: The treatment of atrophic mandibular fractures represents a challenge for the maxillofacial surgeon, due to the peculiarities presented by the intense bone loss.
Keywords: Mandible. Fracture fixation. Atrophy.
1 Hospital Municipal Dr. Mário Gatti, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Campinas/SP, Brazil).
2 Especialista em Cirurgia e Traumatologia Bucomaxilofacial, Hospital Municipal Dr. Mário Gatti (Campinas/SP, Brazil).
Contact address: Lorenzzo De Angeli Cesconetto Rua Francisco Bueno Lacerda, 250, apto 36-B, Campinas/SP – CEP: 13.036-265 E-mail: lorenzzodac@hotmail.com - andrearaujo.odonto@hotmail.com
How to cite: Cesconetto LA, Araújo AVA, Albuquerque Neto AD, Cerqueira DA, Campanha AA. Treatment of bilateral fracture in severely displaced atrophic mandible. J Braz Coll Oral Maxillofac Surg. 2019 Jan-Apr;5(1):53-7. DOI: https://doi.org/10.14436/2358-2782.5.1.053-057.oar
Submitted: January 30, 2018 - Revised and accepted: May 24, 2018
» The authors report no commercial, proprietary or financial interest in the products or companies described in this article.
» Patients displayed in this article previously approved the use of their facial and intraoral photo graphs.
INTRODUCTION
The life expectancy of the elderly population has dramatically increased due to health advances and lifestyle changes. The elderly population (aged 60 and over) in Brazil totaled 19.6 million in 2010, probably reaching 41.5 million in 2030 and 73.5 million in 2060. 1
Mandibular atrophy leads to a decrease in bone mass, making the bone more vulnerable to fracture. It can be considered the final stage of edentulism (total loss of teeth). Tooth loss leads to several biological processes, until loss of the alveolar process. 2
The reduction of fracture fragments and fracture consolidation are impaired by bone atrophy, small contact area contact between fractured segments, reduction of the bone repair capacity and lack of anatomical reference points to guide the alignment of fragments. 3
Luhr et al 4 developed a classification system for fractures of atrophic mandibles based on bone height at the fracture site: bone fractures with less than 20- mm height are considered atrophic; Class I are fractures with bone height 16 to 20 mm; Class II from 11- to 15-mm height; and Class III, less than 10-mm height.
Therapy for atrophic jaw fractures may be open or closed. The conservative treatment includes the use of circumandibular ligatures in existing prostheses, Gunning splints or external fixation. Surgical treatment includes several modalities using the most varied types of rigid internal fixation. 2,3,5,6
CASE REPORT
A 79-year-old female patient presented for evaluation by the Oral and Maxilofacial Surgery and Traumatology team 17 days after having been ran over by a bike, with the chief complaint of facial asymmetry and difficulty in mastication. She had a history of hypertension and diabetes. Upon examination, bone crepitation was observed in the mandibular body region bilaterally, associated with pain upon manipulation. The patient was completely edentulous in both arches and mentioned paresthesia in the inferior alveolar nerve region bilaterally.
Computed tomography of the face was requested, which revealed a fracture line in the body region bilaterally, with severe anterior displacement in anteroposterior and craniocaudal directions (Fig 1).
On the tomographic examination the alveolar ridge presented 7-mm height, scored as Luhr Class III. 4
Due to the degree of mandibular atrophy, it was decided to surgically reduce the fracture and use rigid internal fixation. The procedure was performed under general anesthesia with nasotracheal intubation. The access of choice was submandibular bilaterally, extending to the submental region. After accessing the fractured region, surgical reduction with fracture simplification was performed using three bicortical screws. Then, fixation was performed using a reconstruction plate of the 2.4 locking system on the lateral mandibular border, with four screws in the right body region, three in the left body and five in the symphyseal region (Fig 2). The surgical wound was sutured by planes and no drains were placed.
Computed tomography was obtained in the immediate postoperative period, which revealed that the bone fragments were aligned, and the rigid internal fixation material was well positioned (Fig 3).
The patient was followed for one year, without complications from the surgical procedure.
Figure 1: 3D reconstruction of computed tomography, evidencing bilateral mandibular body fracture with severe displacement. There is loss of continuity of the alveolar ridge on the intraoral image, due to severe displacement of the fracture.
Figure 3: 3D reconstruction of computed tomography postoperatively, demonstrating correct reduction of the fractured segments and satisfactory fixation. The intraoral image exhibits the correct contour of the alveolar ridge after the surgical procedure.
DISCUSSION
The treatment of fractures in atrophic mandibles in edentulous patients is challenging for the oral and maxillofacial surgeon, due to the unfavorable biological and biomechanical conditions. 2
The surgical approach under general anesthesia is often affected by the poor overall status of an elderly patient. Consequently, it is mandatory to decide the treatment correctly since its onset. Advances in the management of polytraumatized patients and in the anesthesia of elderly patients have reduced the surgical risk in these cases. 7
The extraoral access provides direct and wide visualization of the surgical field and allows accurate approximation of the fragments. 6 Some authors suggest that the intraoral access prevents visible scars and lesions on facial nerve branches; however, this increases the risk of infection and lesion to the inferior alveolar nerve. 2,5 The selection criterion should be based on the surgeon’s preference and experience, observing the type of fracture and general conditions of the patient. Rigid internal fixation can be obtained by open reduction techniques and provides greater comfort for the patient, due to the early function of mandibular movements. 2
Some authors suggest the accomplishment of supraperiosteal dissection in fractures in atrophic mandibles, stating that this allows better blood supply to the traumatized region. The major disadvantage of this dissection is the impaired visualization, which complicates the fracture reduction and fixation difficult. 2.5
The evolution of fixation materials allowed the recent development of locking plate systems. This system provides important advantages in the treatment of fractures in atrophic mandibles, especially the possibility of small imperfections on the plate contour. Haug et al 8 demonstrated that fracture stability is not decreased when locking system plates are used with up to 4 mm of the bone surface.
Van Sickels and Cunningham 9 suggest that mandibular atrophy smaller than or equal to 5 mm requires some means to promote osteogenesis, which may involve bone grafting or morphogenetic bone protein (rh-BMP-2). The autogenous bone grafts increase the operative morbidity due to the need of a second surgical area. 5,9,10
Luhr et al 4 treated 84 fracture sites in atrophic mandibles in 65 patients with compressive plates, without bone grafting, observing absence of complications in 81 cases. There were 2 cases of non-union and 1 case of osteomyelitis.
Most articles in the literature that investigate fractures in edentulous patients present a small case series, due to the low incidence. 3
Franciosi et al 3 performed a retrospective 20-year study of patients assisted at Hospital Italiano de Buenos Aires. They observed 18 edentulous patients with mandibular fracture, totaling 35 fracture lines. Among these, 6 lines were treated conservatively because they were condylar fractures. Among the cases, 62% were treated using 2.4 locking system reconstruction plates, 29% with 2.0 locking miniplates and 2 cases with 2.7 locking system reconstruction plates. Success was observed in 96.5% of cases, with non-union in only one case.
Novelli et al 2 treated 16 fractures in edentulous patients, being 8 with the 2.0 locking miniplate system and the other 8 with the 2.4 locking system. There was only one case of complication, in which the plate presented exposure when the 2.4 locking system was used. The use of miniplates was limited to cases scored as Luhr I and II 4 , while thicker plates were used in cases scored as Luhr III.
The treatment of fractures in Luhr Class III 4 atrophic mandibles is based on the use of 2.4 or 2.7-mm locking plates, by extraoral access, and may or may not be associated with the use of immediate graft 2,3,5,6,9,10 .
CONCLUDING REMARKS
The treatment of fractures in atrophic mandibles is challenging for the oral and maxillofacial surgeon. The evolution of rigid internal fixation devices provided greater surgical predictability and allowed early recovery of masticatory functions. The degree of mandibular atrophy should be assessed to choose the most appropriate fixation system, since better results are obtained with the 2.4 locking plate system in Luhr II and III cases.
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