Clinical Outcome of Conservative Treatment of Displaced Mandibular Fracture in Adults

doi:10.4236/ss.2013.411097

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Surgical Science, 2013, 4, 500-505

Published Online November 2013 (http://www.scirp.org/journal/ss)

http://dx.doi.org/10.4236/ss.2013.411097

Open Access SS

Clinical Outcome of Conservative Tr eatment of Displaced

Mandibular Fracture in Adults

Lipa Bodner1*, Sigal Amitay1, Ben Zion Joshua2

1Department of Oral and Maxillofacial Surgery, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University

of the Negev, Beer-Sheva, Israel

2Department of Otolaryngology Head and Neck S urgery, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion

University of the Negev, Beer-Sheva, Israel

Email: *[email protected]

Received September 3, 2013; revised October 1, 2013; accepted October 9, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

The article evaluates 12 cases of conservative treatment of displaced mandibular fractures in adults. Twelve cases of

displaced mandibular fractures treated surgically, either by closed reduction (IMF) or open reduction internal fixation

(ORIF) served as controls. Occlusion, maximal mouth opening, lateral jaw movements, neurological dysfunction

(=sensory deficit), and bone remodeling were evaluated and scored in both groups, and results were compared. No sig-

nificant differences were found between the two groups in all the evaluated parameters. It is concluded that in certain

cases, with displacement of 2 - 4 mm, where a surgical approach is not feasible, reasonable spontaneous reduction and

bone remodeling can occur. Meticulous follow-up is mandatory.

Keywords: Mandible; Jaw Bone; Trauma; Displaced Fracture; Conservative Management

1. Introduction

Fractures of the mandible are generally treated by closed

or open reduction [1]. The aim of the treatment is to re-

duce the displaced fracture and restore proper occlusion

and facial contour. The closed reduction methods involve

intermaxillary fixation (IMF) using splints, arch bars, or

maxillomandibular fixation screws [2,3]. There are seve ral

disadvantages with IMF, including: compromised airway,

poor oral hygiene, speech difficulties, impaired nu tritional

intake with weight loss, and disusing atrophy of the mas-

ticatory muscles. Open reduction and internal fixation

(ORIF) using wires, pins, screws, or plates are among the

common methods [4].

In recent years, ORIF, by allowing immediate mobi-

lization of the mandible, has won increasing acceptance

as the method for treatment of mandibular fractures [5].

Conservative management as a treatment modality is

well accepted in mandibular condylar fractures [6]. Con-

servative treatment in cases of mandibular body fractures

has been reported in children in early childhood age,

[7-12] and in adults with atrophic edentulous mandible

[13-15]. In some reports, closed reduction with IMF was

considered as conservative treatment [16-18].

We are unaware of reports describing conservative

treatment for displaced mandibular fracture in adults.

The purpose of the present report is to follow the cli-

nical outcome of 12 patients with displaced mandibular

fracture treated conservatively in terms of restoration of

mandibul a r f un c t i on.

2. Material and Methods

Twenty-four cases of mandibular fracture were included

in the present study. The control group (n = 12) was

treated surgically by either closed reduction (IMF) or

open reduction (ORIF).

The experimental group (n = 12) was also advised to

undergo surgery, either closed or open reduction. How-

ever, due to personal or medical reasons, they were not

operated on.

The first patient, who was the trigger for the present

study, was a 34-year-old psychiatric female patient with

a displaced fracture of the mandible, who “refused” to

stay at the hospital for surgery. The case was evaluated

by the risk management committee of the hospital, and

the advice was that as the surgery she needed was not a

*Corresponding a uthor.

L. BODNER ET AL. 501

life-saving procedure, it was illegal to hospitalize her

against her will and/or force her toward surgery. Her

parents were involved in the entire process; however, as

she was an adult, they were not eligible to make a legal

decision on her behalf.

For some other participants in the experimental group,

there were medical contra-indications for general anes-

thesia due to comorbid conditions, the legal guardians

were not available, or they refused general anesthesia for

some personal or religious reasons.

Clinical examination of the functional state of the

mandible was performed by one of the authors (LB) as

part of the standardized procedure followed for all jaw

trauma patients at the hospital. The examination included:

occlusion, maximal mouth opening, lateral jaw move-

ments, neurological dysfunction (=sensory deficit), and

bone remodeling. Data were classified according to a

numerical scale, based on the clinical dysfunction index

of Helkimo [19] with modification [20]. The patients

were classified as clinically symptom-free (SF), having

mild symptoms (MS), or having severe symptoms (SS).

The analytical description of the scale system and the

indices used are presented in Table 1. Patients in both

groups were followed routinely in a similar manner. The

follow-up evaluation was done for an average of 12 months

post-treatment. Patients in both groups were asked to

self-estimate the treatment outcome, and score it as either

poor, good, or excellent. A paired t-test was used to

detect significant changes between the experimental and

control gr oups.

Table 1. The index system used for evaluation of mandibular

function.

Normal = 0

Mostly normal = 1 a) Occlusion

Abnormal = 5

>40 mm = 0

30 - 39 mm = 1

b) Maximal mouth

opening <30 mm = 5

>7 mm = 0

4 - 6 mm = 1

c) Lateral jaw

movement <3 mm = 5

Normal sensation of l o w e r lip and gum = 0

Abnormal sensation of lower lip or gum = 1

d) Neurological

dysfunction Abnormal sensation of lower lip and gum = 5

Normal bony union = 0

Incomplete bony union = 1 e) Bone regeneration

Non-union = 5

Score

0 = Symptom free (SF)

1 - 5 = Score 1 = Mild symptoms (MS)

Sum of A + B + C

+ D + E:

6 - 25 = Score 5 = Severe symptoms (SS)

3. Results

The patients’ characteristics and their self-estimation of

treatment outcome are presented in Tables 2 and 3 and

Figures 1-4. The prevalence of mandibular function fol-

lowing surgical and conservative treatment is presented

in Table 4. Evaluation of the function indices showed

Figure 1. Fracture of Lt. angle of a dentate mandible, with 3

mm displacement, treated conservatively (Table 2, case 1).

Figure 2. Outcome of the conservative treatment one year

post trauma. Complete bony regeneration can be seen.

Figure 3. Fracture of the Rt. body of an edentulous man-

dible, with 4 mm displacement, conservative treatment (Ta-

ble 2, case 12).

Figure 4. Outcome of the conservative treatment, one year

ost trauma. Good bony regeneration can be seen. p

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L. BODNER ET AL.

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502

Table 2. Characteristics of patients with displaced mandibular fracture in the experimental (conservative treatment) group.

Age Sex Location of fracture Displacement

Vertical/horizontal Dentate (D)

Edentulous (E)Reason for no

treatment Self-estimation of outcome

Poor/good/excellent

1 34 F Lt. angle 3 mm Vertical D Psychiatric

ti t

Excellent

2 43 M Rt. Body 2 mm Horizontal E MCI Excellent

3 71 F Rt. Body 3 mm Vertical E MCI Good

4 62 M Lt. Angle 2 mm Vertical D LSU Excellent

5 26 M Rt. Angle 2 mm Vertical D PsychEt

Ls 2

Lt. isis 2

iatric patient xcellen

6 41 M Lt. Angle 2 mm Vertical D LSU Excellent

7 81 M Rt. Body 4 mm Vertical E MCI Poor-good

8 15 M t. Symphisi mm HorizontalD ALG Excellent

9 83 M Parasymph mm HorizontalE MCI Good

10 21 M Rt. Body 2 mm Horizontal D LSU Excellent

11 64 M Rt. Ramus 2 mm Horizontal D MCI Good

12 79 F Rt. Body 4 mm Vertical E MCI Good

le 3araristics of pith displacedacture in the control (operative treatment) gn = 12). Tab. Chcteatients w mandibular frroup (

Age Sex Location of

fracture Displacement

Vertical/horizontal Dentate (D)

Edentulous (E) Type of treatment

IMF/ORIF Self-est imation of outcom e

Poor/good/excellent

1 30 F Lt. Angle 3 mm Vertical D IMF Excellent

2 43 M Lt. Body 2 mm Horizontal E ORIF Excellent

3 71 F Rt. Body 3 mm Vertical E ORIF Good

4 62 F Rt. Angle 2 mm Vertical D IMF Gont

Ls 2

Lt. Pisis 2

od-Excelle

5 26 M Rt. Angle 2 mm Vertical D IMF xcellen

6 41 M Lt. Angle 2 mm Vertical D IMF Excellent

7 81 M Lt. Body 4 mm Vertical E ORIF Good

8 15 F t. Symphysi mm HorizontalD IMF Excellent

9 83 M arasymph mm HorizontalE ORIF Good

10 21 M Lt. Body 4 mm Horizontal D IMF Excellent

11 64 M Rt. Ramus 2 mm Horizontal D IMF Good

12 79 F Rt. Body 4 mm Vertical E ORIF Good

Tab. The p of mation followi surgical and vative treatmen

imental) n (%)

le 4revalencendibular funcngconsert.

Score No. Surgical (control) n (%) Conservative (exper

Occlusion 3 0 = SF 11, 92 10, 8

1 = MS

5 = SS 1, 8

0 2, 17

Maximening

N 2, 1

al mouth op0

12, 100

Lateral jaw m o vement 0

12, 100

eurological dysfunction0

10, 83

11, 92

, 8

Bone regeneration 0

11, 92

1, 8

10, 83

2, 17

that gecant differences we found be-

een the control and experimental groups (p > 0.05).

(range 15 - 83), respectively. The M:F ratio was 3.0 and

2.0 in the rimental and control groively.

The mean displacement was 2.50 and 2.66 mm in the

lent in 7 (58%) patients, good in 4 (33.3%) patients, and

nerally no signifire

The mean age of the patients in the control group and

experimental group was 52.8 (range 18 - 83) and 51.6 experimental and control groups. The self-estimation of

treatment outcome in the experimental group was excel-

eexpuprespects,

L. BODNER ET AL. 503

poor-good in 1 (8%) patient. The self-estimation of

treatment outcome in the control group was excellent in 6

(50%) patients, good-excellent in 1 (8%) patient, and

good in 5 (42%) patients. The differences were not sig-

nificant (p > 0.06).

The occlusion score was 92% SF and 8% MS com-

pared to 83% SF and 17% MS in control and experi-

mental groups, respectively. The scores for maximal

mouth opening and lateral jaw movement were SF

(100%) in both groups. The neurological dysfunction

score was 83% SF and 17% MS compared to 92% SF

literature on complication rates of

res revealed that it ranges from 7 to 29

fixation and open reduction and

infection from ORIF, malo-

ion is discussed with the

ucosa at the fracture area. Only

surgery for

r treatment of clavicle fractures, where mini-

where no other treatment modality

d 8% MS in control and experimental groups, res-

pectively. Bone regeneration score was 92% SF and 8%

MS compared to 83% SF and 17% MS in control and

experimental groups, respectively. The differences be-

tween the control and experimental groups were not sig-

nificant (p > 0.06).

4. Discussion

The study was undertaken to determine if conservative

treatment of patients with displaced mandibular fracture

results in normal jaw function or with increased risk of

possible dysfu nct i on

Reviewing the

mandibular fractu

per cent [21]. The complication rate has been correlated

more to the severity of fracture and less to the type of

treatment. No difference in complication rate was found

between intermaxillary

ternal fixation [22]. It was concluded that in fractures

with displacement of 2 to 4 mm, there is no difference

between closed reduction and open reduction. Our in-

terest was to look at a group of patients with displa-

cement of 2 - 4 mm, treated conservatively, and follow

the rate of complications.

Alpert et al. [23] described four types of complications:

1) those arising in the course of proper treatment, 2)

those arising due to inappropriate treatment, 3) those due

to surgical failure, and 4) those that result from no treat-

ment. They also gave examples for each type of com-

plication, such as wound

lusion from improper treatment, injury to the marginal

mandibular nerve due to technical mistakes, and malo-

cclusion from no treatment.

In the present series, 12 patients were treated con-

servatively. The results are more than satisfactory, as

they are very similar to the results of patients treated by

closed (IMF) or open reduction (ORIF). It has to be

emphasized that conservative treatment does not mean

“no treatment”. The situat

tient and/or with his family that under the specific

circumstances, the conservative treatment is in fact the

treatment of choice. The patients were routinely followed

once a day, once a week, and later once a month, and the

progress or no prog ress w as evaluated p er each visit. Th e

option of chang ing treatment modality toward ORIF was

always on the table.

Among the dentate patients, normal occlusion is the

key factor that is evaluated during each follow-up visit.

Also, the need to be on a liquid/soft diet is emphasized

each visit. The edentulous patients were instructed not to

use their dentures for several months, in order to prevent

pressure-sores of the m

ter 12 - 16 weeks and radiographic evidence of bony

union of the mandible, was the denture relined with a

soft-liner and put back in place. Complete bony union

and remodeling of the displaced fracture is an age-de-

pendent process. Among the younger patients the process

was faster, lasting 3 - 6 months compared to the older

patients where it lasted one year or more until they were

able to masticate normally with their natural teeth or

dentures. Each of the patients was a unique professional

challenge that was followed very carefully.

Conservative or non-surgical treatment, consisting of

observation and soft diet only, has been reported as a

treatment option in greenstick or non-displaced mandi-

bular fractures with normal occlusion [24,25]. In the

report by Ellis et al., [24] 687 patients, 32% of the total

sample of 2137 patients, did not undergo

rrection of their mandibular fracture and were

observed for 4 - 6 weeks. Ghazal et al. [25] reported on

28 cases of mandibular fractures that were managed by

observation and soft diet only. This conservative appr oac h

resulted in spontaneous healing of the fractures. The

hypothesis is that with greenstick and non-displaced frac-

ture, the periosteum is intact, and therefore may maintain

sufficient stability for interfragmentary motion not to

exceed the level tolerated by bone, thereby permitting

ossification. However, in displaced fracture the perios-

teum is probably damaged, the gap and motion between

fragments are larger, which may interfere with ossifica-

tion. Therefore, the common approach is closed or open

reduction.

In our series, the displacement was 2 - 4 mm, which is

considered a mild displacement. It is hypothesized that in

cases with displacement larger than 4 mm, where the risk

of non-union is much greater, the conservative approach

might be more risky. Similar clinical thoughts have been

reported fo

ally displaced or non-displaced fractures can be treated

non-surgically, whereas displaced fracture has to be

treated by ORIF [26].

5. Conclusion

Conservative treatment of displaced fracture of the

mandible carries higher risk of complications compared

to IMF or ORIF. However, in certain cases, with dis-

placement of 2 - 4 mm,

Open Access SS

L. BODNER ET AL.

504

is feasible, it can be a treatment option with respectable

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datory.

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