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 Table of Contents  
Year : 2021  |  Volume : 15  |  Issue : 1  |  Page : 51-60

Clinical applicability of three-dimensional plates in mandibular angle fractures - A review

1 Graded Specialist (Oral and Maxillofacial Surgery), 11 CDU, Chandigarh, India
2 Consultant (Oral and Maxillofacial Surgery), Command MilitaryDental Centre (Western Command), Chandigarh, India
3 Department of Oral and Maxillofacial Surgery, Army Dental Centre (Research and Referral), New Delhi, India
4 Classified Specialist (Oral and Maxillofacial Surgery), Airforce Institute of Dental Sciences, Bengaluru, Karnataka, India

Date of Submission17-Feb-2020
Date of Decision26-Nov-2020
Date of Acceptance15-Jan-2021
Date of Web Publication09-Mar-2021

Correspondence Address:
R Arunkumar Shadamarshan
11 CDU, C/0 56 APO
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JODD.JODD_8_20

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Fractures involving the angle of the mandible has been a long-term controversy next only to the condylar fractures. Several methods and hardware configurations exist in literature with its attendant advantages and disadvantages. A study was conducted to provide a comprehensive review of existing literature regarding the utility of three-dimensional plates (3DPs) in the management of mandibular angle fractures (MAFs). Electronic database was searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines without date and language restrictions. The inclusion criteria were human studies in the form of randomized control trials, non-randomized trials and comparative studies, retrospective studies, prospective studies, and observational studies with at least one of the treatment arms including management of MAF using 3DP. Case reports/case series, technical notes, letters to the editor, studies which do not report the results of MAF management with 3DP separate from other fractures of the mandible, and laboratory/model/computer simulation-based/ animal studies were excluded. The relevant data of the selected articles were tabulated and compiled for review. Twenty-seven articles were included in the review among which 3 were systematic reviews, 12 were found to be observational studies in a prospective or retrospective manner without controls, and 12 were comparative studies with a control group. Based on the review, it can be concluded that 3DP in MAF can be used as an effective alternative to standard miniplates with comparable clinical utility if not superior but with a definite inclination toward less complications.

Keywords: Mandibular angle fractures, three-dimensional miniplates, strut plates, grid plates

How to cite this article:
Shadamarshan R A, Roy Chowdhury SK, Saxena V, Rajkumar K. Clinical applicability of three-dimensional plates in mandibular angle fractures - A review. J Dent Def Sect. 2021;15:51-60

How to cite this URL:
Shadamarshan R A, Roy Chowdhury SK, Saxena V, Rajkumar K. Clinical applicability of three-dimensional plates in mandibular angle fractures - A review. J Dent Def Sect. [serial online] 2021 [cited 2021 Apr 18];15:51-60. Available from: http://www.journaldds.org/text.asp?2021/15/1/51/310975

  Introduction Top

Mandible, the only mobile bone of the face owing to its prominence, is commonly involved in trauma. About 19%–40% of all facial fractures are fractures of the mandible, and 12%–30% of all mandibular fractures are fractures of the mandibular angle (MAFs).[1],[2],[3] The etiology of these injuries varies between different studies. However, the most common etiology of MAF is attributed to sports injuries, followed by interpersonal violence and high-velocity road traffic accidents.[4] Sudden change in the orientation of the mandible, reduced cross-sectional area, presence of impacted teeth, and sudden change in the orientation of grain structure have all been attributed to the increased incidence of these fractures.[5] Treatment of MAF has been a subject of controversy with no consensus till date.[6] These fractures tend to create most complications when compared to other fractures of the mandible.[7] The presence of impacted teeth, reduced cross section, proximity of the inferior alveolar canal, inherent biomechanical issues of the mandibular angle, and involvement of the muscular attachments in causing displacements tend to make the treatment complicated.[8] However, consensus may be believed to have been reached in the fact that open reduction and internal fixation (ORIF) of MAF is the gold standard since maxillomandibular fixation does not result in the stability of the proximal fragment leading to anterosuperior rotation of the proximal fragment.[9] The aim of any plating technique is to achieve as close an anatomical reduction as possible and to ensure bone healing in that position. This needs to be carried out without compromising on the most important objective of establishing a functional occlusion with restoration of masticatory efficiency. Two fundamentally different concepts of fixation exist rigid fixation which uses a rigid plate with bicortical screws along the lower border to ensure direct bone healing[10] and another, the Champy's system of establishing a functionally stable fixation using miniplates.[6] Obvious disadvantages of rigid fixation include extraoral approach with consequent scarring, facial nerve damage, and increased operation time. Several schemes of application of miniplates have been used for treatment of MAF. The most commonly used method of fixation is the use of a single miniplate along the external oblique ridge (Champy's technique) followed by the two-miniplate technique.[6] Several authors observed gaps at the inferior border of the mandible, lateral displacement of the fracture segments, and posterior open bite using the Champy's technique[11] which led to the placement of another miniplate at the lower border to prevent anteroposterior and lateral displacement of the fragments. This placement led to increased postoperative complications including infections.[12] To overcome the effect of distraction at the lower border and to reduce postoperative complications, three-dimensional (3D) plating system was developed.[13] Titanium 3D miniplating system was introduced by Mustafa in 1992.[13] Since then, several studies have been carried out to establish the clinical efficacy and application of these plates in mandibular fractures, including the angle region. However, the availability of quality evidence to prove its superiority to conventional miniplates in the form of randomized control trials (RCTs), especially as it relates to the mandibular angle, appears to be scanty in literature. The aim of this paper is to provide a comprehensive descriptive review of literature in the use of 3D plates (3DPs) in MAF to enable practicing maxillofacial surgeons to understand the current trends, results, and complications in this treatment without complicated statistical jargon.

  Materials and Methods Top

Literature search

A systematic electronic search of PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Medline-Ovid, SpringerLink, Embase, Scopus, and ScienceDirect was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement[14] initially in September 2017 and then further in November 2020 (before uploading the revised version). A manual search of the oral and maxillofacial surgery-related journals including the Journal of Oral and Maxillofacial Surgery, International Journal of Oral and Maxillofacial Surgery, British Journal of Oral and Maxillofacial Surgery, Journal of Craniomaxillofacial Surgery, Journal of Craniofacial Surgery, Journal of Maxillofacial Oral Surgery, Journal of Oral Surgery, Medicine and Pathology, Oral and Maxillofacial Surgery, Oral Surgery, Oral Medicine, Oral Pathology, Oral radiology, Plastic and Reconstructive Surgery, and Journal of Craniomaxillofacial Trauma and Reconstruction. When reviews, systematic reviews, and existing meta-analyses were found, the same was scanned for possible additional sources.

Keywords for search

The keywords and combinations used for the search included “Three dimensional plates” OR “3D plates” OR “three dimensional miniplates” OR “3D miniplates” OR “strut plates” OR “grid plates” AND “mandibular angle fracture” OR “fracture angle of mandible.” The string used in PubMed is ([Three dimensional plates] OR [3D plates] OR [three dimensional miniplates] OR [3D miniplates] OR [strut plates] OR [grid plates]) AND ([Mandibular angle fracture] OR [fracture angle of mandible]).

Inclusion criteria

  1. Human studies
  2. RCTs
  3. Nonrandomized trials
  4. Retrospective studies
  5. Prospective studies
  6. Observational studies
  7. At least one of the treatment arms includes management of MAF using 3DP.

Exclusion criteria

  1. Case reports/case series
  2. Technical notes
  3. Letters to the editor
  4. Studies which do not report the results of MAF management with 3DP separate from other fractures of the mandible
  5. Laboratory/model/computer simulation-based/animal studies.

  Results Top

A total of 84 articles were identified from the electronic search while 53 additional sources were found from the existing reviews, systematic reviews, and meta-analysis. After removal of duplicate articles, a total of 96 articles were screened. On initial screening, 59 records were excluded due to not fulfilling the inclusion criteria. Thirty-seven full-text articles were assessed for inclusion among which 10 were excluded due to various reasons [Figure 1]. The flowchart for article selection is depicted in Figure 1. The salient features of all the studies are depicted in [Table 1] and [Table 2].
Figure 1: PRISMA flowchart

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Table 1: Summary of articles with utilization of 3DP in MAF

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Table 2: Summary of systematic reviews comparing 3DP and standard miniplates in the management of MAF

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  Discussion Top

ORIF has been long established as the standard for the management of MAF.[7] However, controversy still exists in relation to the selection of the type of fixation and hardware configurations for the management of these fractures. Several configurations have been proposed and studied in the literature. 3DP is a latest addition to the armamentarium of the maxillofacial surgeon in the fixation of MAF. Several studies have been carried out in retro/prospective observational manner and as controlled trials in establishing the necessity and efficacy of these plates.

On reviewing the existing literature, the following points can be noted:

  1. Existence of minimal literature in the form of RCT

  2. Among the 27 articles included in the review, 3 were systematic reviews,[1],[15],[16] 12 were found to be observational studies in a prospective or retrospective manner without controls,[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28] and 12 were comparative studies with a control group.[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40] Among the comparative studies, there were only 4 well-designed RCTs for the management of MAF

  3. Nonstandardization of control group

  4. Even with the existence of 4 randomized studies,[31],[32],[39],[40] only 3 of them use the Champy's functionally stable fixation (most widely used for MAF) as the control group for the study.[32],[39],[40] Many of the nonrandomized comparative studies, however, compare 3DP with Champy's system of MAF management[29],[33],[34],[35],[36],[37]

  5. Majority of the available literature is retrospective or prospective observational in nature leading to reduced quality of evidence
  6. Nonstandardization of the hardware used in the study

  7. The term 3DP is a misnomer since these plates prevent 3D forces from acting on the fracture fragment, namely shearing, bending, and torsion, and are not merely 3D in nature.[15] These plates are made of titanium or stainless steel[36] and come in a variety of hole configurations such as 2 by 2, 3 by 2, 4 by 2, and 5 by 2 for mandibular applications. In general, the profile of these plates is 1 mm and that of the interconnecting struts is 0.8 mm. There are two configurations available: straight and curved. Based on the configuration, these plates are also referred to as grid plates and strut plates. The configurations of the plates used in the study are mentioned in Table 1. Although standardization does not exist, the common feature of these plates is the presence of interconnecting vertical struts between the horizontal bars which enables better biomechanical advantage by providing cross stabilization in a 3D manner

  8. Nonstandardization of the type of fixation used in the concomitant fracture causing bias in the observations

  9. Most of the MAFs are associated with concomitant fractures of the contralateral side of the mandible. To validate the effect of 3DP of the angle fractures, the concomitant fracture needs to undergo rigid fixation. Most of these studies do not incorporate this concept.[20] Functionally stable osteosynthesis has been used in the concomitant mandibular fracture in most of the cases. If that has been the case, it can definitely be concluded that the results and especially the complications may be influenced by the concomitant mandibular fracture, most commonly occurring in the dentate segment. For instance, malocclusion and neurosensory deficit may be influenced by the concomitant parasymphysis fracture. However, conducting studies with isolated angle fracture may be not be clinically feasible due to the relative rarity and the clinical applicability of it when compared to bilateral fractures of the mandible.

  10. Nonstandardization of the surgical approach used in the management of MAF or the concomitant fracture leading to bias in the observations.

  11. There seems to be no consensus on the approach used for the management of MAF, whether intraoral or extraoral. Although most of the studies have used a transoral approach with or without the use of transbuccal trocar and cannula under general anesthesia, the procedure can be carried out using local anesthesia using an extraoral approach also. Some of studies mentioned utilize the extraoral approach.

  12. Conflicting results, observations, and opinion regarding the efficacy and the use of these plates in the management of MAF.

  13. The systematic analyses and the meta-analyses[1],[15],[16] is summarized in Table 2. Only two of these studies have dealt with 3DP in MAF while one has dealt with all types of hardware in the management of MAF.

Most of the studies included in the review have demonstrated stark advantages to the use of 3DP in MAF. Most of these advantages are inclined toward development of lesser complications and providing greater stability. The main advantages of using these plates include simultaneous stabilization of both tension and compressive sides of the fracture, improved malleability and adaptability of the plates with minimal distortion and displacement of the fracture segments, easy applicability, avoidance of extraoral approach, or time-consuming approach for dual plating and thereby reducing complications.[19] These plates offer the most required added advantage of increased biomechanical stability with less hardware. It has been found that 3D 1 mm plate was as stable as the much thicker 2-0 miniplate with better resistance to bending and out of the plane movements.[28] Further studies on sheep hemimandible revealed better biomechanical behavior of 3D plates than Champy's technique but not significantly different from that of monoplanar or biplanar plate placement techniques.[41] Most of the studies that declare superiority of 3DP have demonstrated lesser complications in terms of infection, hardware failure, and postsurgical neurosensory deficit. Equally, many studies have demonstrated equivalence with the existing Champy's system and have therefore questioned the unnecessary introduction of a newer system which provides only comparable results. The conclusion of the studies along with the demonstration of overall advantage/equivalence/disadvantage is depicted in Table 1. In spite the existing conflicts in the observations, it can be conveniently concluded that no study has demonstrated any gross inadequacy of 3DP in the management of MAF. However, considering the systematic reviews, it can be seen that, though the clinical utility remains the same in producing optimal results, 3DP has considerably less chance of overall postoperative complications, especially in relation to hardware failure and infection. Thus, similar clinical applicability and less infections form a best combination for sincere consideration in the utility of these plates or management of MAF.

  Conclusion Top

It seems to be a general consensus that 3D strut plates can be used as an effective alternative to Champy's method of osteosynthesis or other prevalent fixation systems of the mandibular angle. The advantages include 3D stability, obviation of buccolingual/inferior border gaping, utilization of the concept of fixation along tension and compression zones using a single plate, comparable rates of infection, low incidence of plate exposure, and low incidence of new postoperative paresthesia. The reduction in operative time seems to be controversial. Although the clinical performance of these plates has been well established by a number of studies, lack of multicentric prospective RCTs with large sample size does not provide quality statistical backup for the superiority of the 3D plates. A large sample multicentric RCT with isolated mandibular angle fractures will go a long way in establishing the actual role and assessment of the outcomes without a concomitant second site fracture as bias. It is also brought to notice that all the studies included a second site of mandibular fracture at various locations which have the inherent capability to cloud the outcome variables.

However, it can be concluded based on the review of the above studies that 3D strut plating of the mandibular angle can be used as an effective alternative to several existing fixation systems, especially to standard miniplates with comparable clinical utility if not superior but with a definite inclination toward less complications.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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