Diagnosis in Treatment of Fractures of the Atrophic Mandible. A Case Series
Patients treated for atrophic mandibles were seen in a 7-year time period in the Oral and Maxillofacial Surgery Department at Case Western Reserve University (Cleveland, OH) and associated hospitals. Patient inclusion criteria include mandibular bone less than 20mm in height, complete mandibular edentulism, and unilateral or bilateral fractures of the mandible due to pathology or trauma. The patients were classified using the Luhr Classification (Class I bone height is 16 to 20mm, Class II bone height is 11 to 15mm and Class III with a bone height of 10mm or less). Electronic as well as film radiographs were used to determine the bone height and the location of the fracture. Patient information (including age, sex, DOB and MRN) was obtained from the Oral and Maxillofacial Surgery Department at Case Western Reserve University patient data base.
A total of 8 patients (age range 57-94 years) fit inclusion criteria, presenting preliminary results. All patients had systemic morbidities including HTN, which was the most common between the patients along with anxiety and depression. Two of the eight patients had osteoarthritis and one patient received radiation therapy for breast cancer. Five of the patients presented with bilateral fractures of the mandible and the other 3 presented with unilateral fractures of the mandible, one of which was a non-union. Mandibular bone height in the fracture line was measured and patients were classified using Luhr Classification. Three patients were Luhr Class III, 3 were Luhr Class II and the remaining 2 patients were Luhr Class I.
All fractures were approached with an apron incision to the neck staying below the level of the platysma. The mandibular fractures were reduced and fixated with titanium plates and screws. In 6 of the 8 cases, autogenous bone was harvested from the anterior iliac crest to augment the vertical height of the bone in the region of the fracture(s). Bone mesh was used in 6 of the 8 patients and placed using a customized resorbable crib. The mesh was fixated with sonic weld screws. No intraoperative complications were reported. One patient presented with a post-surgical complication of abscess in the submandibular space and dehiscence of the intraoral incision. The infection was addressed with incision and drainage of the area, and resolved without further complication.
The protocol used by Ellis and Price of open reduction and internal fixation with immediate bone grafting in atrophic mandible fractures may seem aggressive therapy for this patient population. However, as they demonstrated and as the preliminary results of this study indicate, patient outcome is favorable. Morbidity from the surgery is low, and patients regain better function than from more conservative therapy.
References:
Ellis E, Price C. Treatment Protocol for Fractures of the Atrophic Mandible. J Oral MaxillofacSurg 66:421-435, 2008.
Luhr H, Reidick T, Merten H. Results of Treatment of Fractures of the Atrophic Edentulous Mandible by Compression Plating: A Retrospective Evaluation of 84 Consecutive Cases. J Oral MaxillofacSurg 54:250-254, 1996.