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Yern Ain

on 12 December 2014

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Malunions can be defined as a bone union of the fracture in which some displacement of the bones still exists. Malunions occur in
0–4.2% of fractures.
Malunions result from improper reduction, insufficient immobilization, poor patient compliance, and the improper use of rigid internal fixation







Complications following mandible fracture repair may be the result of the severity of the original injury, the surgical treatment or patient non-compliance with the postoperative regimen

The consequences of complications may include problems in anatomic form (cosmetic deformity) or residual functional disturbances.
Residual arch form deformity following the surgical repair of a mandibular fracture is often the result of inadequate reduction.
Failure to re-establish the anatomic configuration of the arch form result in occlusal prematurities and misalignment which will compromise masticatory function.
Poor apposition of fracture segments may results from a delay in or an absence of treatment, inadequate treatment, inability to align segments secondary to the presence of a foreign body or loss of bony landmarks.

When the discrepancies are not caught early, the fracture segments will go on to heal in the improper anatomic position (malunion)

Significant malunions of the mandible will produce asymmetry and/or functional disturbances and can only be resolved through carefully planned osteotomies for reconstruction of the mandibular arch form.

Malocclusion can be corrected by further or prolonged IMF in the early stages of healing, and selective tooth grinding, orthodontics, or osteotomies after complete bony union

Comprehensive management of malocclusion and malunion requires a full orthognathic workup
Delayed union by definition means that the fracture will eventually heal without further surgery; failure of fracture union by 2 months.

Infection, mobility, systemic disease, advanced age, and mandibular atrophy are contributing factors of delayed union

Rigid internal management of mandibular fracture fixation carries a lower incidence of delayed union compared to nonrigid fixation:
0–2.8% versus 1–4.4% (Koury M., 1997)
Nonunion is the failure of a fracture to unite owing to arrested healing and require additional treatment to achieve fracture union

Mobility is the major cause of nonunion

More than 33% of nonunions involve infection

Large bony gaps, traumatized devitalized tissue, older age, intervening soft tissue, and systemic disease all can contribute to nonunion.

Debridement of the fracture fragments, bone grafting (usually from the iliac crest) and rigid fixation with internal or external fixation usually achieves fracture union.
Sensory nerve injury, particularly of the inferior alveolar and mental nerves, commonly occurs with mandibular fractures

Most injuries are neuropraxias secondary to stretching or compression and resolve spontaneously.

Return of nerve function depends on the
degree of initial trauma to the nerve and an
accurate reduction and adequate fixation
of the mandibular fracture

Rarely other branches of the mandibular division of the trigeminal nerve can be affected;
i) masseteric nerve,
ii) auriculotemporal nerve (both with condylar fractures),
iii) buccal and lingual nerves associated with intraoral lacerations with body or angle fractures.
There is a greater incidence of TMJ pain, deviation on opening and joint noise in patients with previous condylar fractures

The resultant internal derangement primarily occurs in adults and is of two broad types.

i) Internal derangement that occurs on the
side of the fracture and results from soft
tissue injury within the joint
- Open reductionwith direct repair of the injured soft tissues has been advocated to prevent this problem

ii) Internal derangement occurs contralateral
to the condylar injury - “condylar postfracture syndrome.”
-Patients who develop a unilateral hinge type of joint after a fracture can rapidly develop overfunction of the contralateral joint with hypermobility and, ultimately, anterior dislocation of the disk
It is more likely to occur in children and is associated with intracapsular fractures and immobilization of the mandible.

The most commonly accepted etiology is of intra-articular hemorrhage, leading to abnormal fibrosis and ultimately ankylosis

In children, if left untreated, it results in disturbed growth and underdevelopment of the affected side

Factors contributing to the development
of ankylosis ; the site and type of fracture, age at the time of injury, duration of IMF, and the extent of damage to the disk

Infection, the most common complication of mandibular fractures, is reported in 0.4–32%of all cases

“Infected mandibular fracture” whenever there is “frank purulent drainage from the fracture site, either intraoral or through extraoral fistula in chronic cases or as associated facial cellulitis in acute presentation

Mandibular fractures are reported to be associated with the highest rate of infections among other maxillofacial fractures -
- This is likely due to instability of the segments from muscular actions on the proximal and distal segments and the density of the bone.

Higher MISS (Mandibular Injury Severity Score) score was significantly associated with an increased risk of inflammatory complications
Risk factors :
- Patient-related factors :
Aging : associated with systemic diseases
Substance abuse: Smoking, alcohol

Smoking has been suggested to have a considerable role in the development of infection, wound dehiscence, and compromised osseous tissue regeneration

Smoking is reported to retard bone healing, adversely affect bone mineral density, and
even to increase the risk of osteomyelitis

Negative effect of alcohol on bone healing is well known due to impaired nutrition


Bradley JC. Age changes in the vascular supply of the mandible. Br Dent J 1972; 132(4):142–144.

Koury M, Ellis E. Rigid internal fixation for treatment of infected mandibular frac‐
tures. J Oral Maxillofac Surg 1992; 50:434–443.

Koury M. Complications of mandibular fractures. In: Kaban LB, Pogrell AH, Perrot D, eds. Complications in Oral and Maxillofacial Surgery. Philadelphia: WB. Saunders, 1997:121–146

Potter J, Ellis E. Treatment of mandibular angle fractures with a malleable noncompression miniplate. J Oral Maxillofac Surg 1999; 57:288–292

- Time between fracture and treatment

In certain situations, delayed “medical
treatment” may increase the incidence of infection.

- Tooth in the line of fracture

Even with clinically sound teeth, contamination can still occur through the involved periodontal ligament.

The socket forms a huge channel for bacterial
invasion, which is usually difficult to control especially when MMF is used

Most surgeons agree to the concept of removing the tooth only if presented with loss of vitality, root fracture, loosening, or when interfering with fracture reduction or occlusion.

Leave the tooth : closely check for its vitality
after fracture consolidation to perform endodontic treatment whenever loss of vitality is noted

- Open versus closed reduction

Closed reduction is reported to be associated with lower rates of postoperative complications

The higher incidence of postoperative complications with open reduction has been ascribed to exposure of the fracture site as well as the hardware to the oral cavity flora

More invasive surgical treatment with wide exposure is usually required for severe traumatic injuries. This decreases vascularity owing to periosteal elevation
and increases the possibility of wound dehiscence and contamination.

- Rigidity of fixation

Inadequate stability and interfragmentary mobility
is reported to be associated with a greater tendency of infection

Fracture instability is known to retard bone healing through interfering with proliferation of capillaries across the gap

Interfragmentary movement has been suggested to introduce microorganisms into the fracture site.

A loose internal fixation device acts asa foreign body and hence induces infection.

Consequently, errors arising from poor plate adaptation, screw-holes drilling, or screw placement can result in interfragmentary mobility that increases the risk of infection.

In a study including 32 patients with oblique infected mandibular fractures, Ghanem et al used a single 2.3 mm reconstruction plate and reported no ostoperative complications. These authors compared two groups; one with the 2.3mm reconstruction plate fixed
with 3 screws on each side and another group with the plate fixed with 2 screws on each side followed by MMF. They reported a higher rate of bone formation in the first group as revealed by postoperative follow up radiographs.

A balance between interfragmentary micromovement and macromovement determines whether the vascular ingrowth will be stimulated or broken down

For successful treatment, the osteosynthesis device must provide adequate stability, which controls the interfragmentary movements without necessarily preventing it completely.

Interfragmentary micro movements are reported to help fracture healing by stimulating external callus formation.

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