|Year : 2019 | Volume
| Issue : 1 | Page : 1-7
The use of microplates for fixation of mandibular fractures: a systematic review
Magdy M Zaky1, Nabila A Fayed2, Mohamed F Shehab2, Usama S Hellal3
1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Cairo University, Cairo; Department of Oral and Maxillofacial Surgery, Alahrar Teaching Hospital, Zagazig, Sharkia Governorate, Egypt
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Cairo University, Cairo, Egypt
3 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Cairo University; Department of Orodental Genetics, National Research Center, Cairo, Egypt
|Date of Web Publication||18-Jul-2019|
Magdy M Zaky
44837 Ghazalet Elkheis, Bairly, Kfr Denohia, Zagazig, Sharkia Governorate
Source of Support: None, Conflict of Interest: None
Microplates have thin diameter making them less palpable, more malleable, easily applied, and adaptable to fracture site. In the past, microplates were used in midface fractures only, but we can obtain their benefits in mandibular fractures as well.
The aim of this systematic review was to verify the efficiency of microplates either alone or in combination with miniplates for fixation of mandibular fractures in comparison with miniplates.
Materials and methods
A systematic review was conducted using electronic databases for collecting articles that met the inclusion and exclusion criteria. Data were extracted from each article, and the quality of studies was assessed by Jadad scale. Four articles were selected that met the inclusion and exclusion criteria.
Microplates have high holding power and were efficacious for internal fixation of simple, minimally displaced, isolated mandibular fractures, but to support this information safely, numerous future studies with sound method and larger sample size are needed to evaluate their use in the other forms of mandibular fractures.
Keywords: Fixation, mandibular fracture, microplates
|How to cite this article:|
Zaky MM, Fayed NA, Shehab MF, Hellal US. The use of microplates for fixation of mandibular fractures: a systematic review. J Med Sci Res 2019;2:1-7
|How to cite this URL:|
Zaky MM, Fayed NA, Shehab MF, Hellal US. The use of microplates for fixation of mandibular fractures: a systematic review. J Med Sci Res [serial online] 2019 [cited 2023 Mar 21];2:1-7. Available from: http://www.jmsr.eg.net/text.asp?2019/2/1/1/262973
| Introduction|| |
Managing mandibular fractures necessitate the restoration of esthetics and functions, and this can be achieved through the anatomic reduction of the fractured mandible and restoration of the original occlusion. Different fixation techniques have been developed passing from the historical era of external fixation to internal fixation.
Different means of fixation are available, for example, commonly miniplates and reconstruction plates used alone or together, to treat simple and comminuted mandibular fractures. However, these plates are of large size and may be palpable through the thin skin and the gingiva. The space available in the upper half of the mandible is limited for a large miniplate, which can result in many complications such as wound-healing problems and dental and neurovascular injuries.
In the literature, many cases are reported in which metal depositions were found in the tissues adjacent to titanium microplates and miniplates or in peripheral organs following osteosynthesis,. Size and amount of osteosynthesis material used should therefore be minimized as much as possible. It is difficult to calculate how much a reduction of the total amount of titanium used will decrease deposition of metal ions in the peripheral organs. Nevertheless, it should be the foremost aim to use as little osteosynthesis material as possible.
Microplates are now commonly used to restore maxillofacial fractures because they require less manipulation, they are more malleable and easier to adapt to the shape of the bone, they are less likely to cause iatrogenic damage, and they are associated with a lower rate of major complications than miniplates.
Previously, microplates were used in non-stress-bearing areas such as midface. This may be because most surgeons do not believe that the microplate fixation system is strong enough to withstand the masticatory forces of the jaw during the formation of a stable bony union, but recent experimental and clinical studies have shown that microplates can be used efficiently in the stress-bearing areas of the mandible,,.
Using microplates allows less invasive surgery, higher degree of adaptability to the fracture site, and better occlusal self-adjustment. The microplate technique is performed with minimal effort, more convenient access, and less stripping of the surrounding periosteum. The screw of the miniplate and microplate is identical, but the microplate screws are smaller in diameter and the risk of injuring the dental root or mandibular nerve is reduced.
Application of microplates is quick because little or no adaptation is necessary, which minimizes the time of surgery and effort of the surgeon. Microplates provide the surgeon with a viable option in the fixation of bony segments owing to their thinness and flexibility to adapt to the mandible by itself while tightening the screws, and minimum pressure is required during tightening of the screws as excessive pressure can lead to breaking of screw head.
In an experimental study, Feller et al. found that treatment of fractures in the interforaminal region with a combination of microplate and miniplate will be stable enough for early mobilization. Moreover, Gupta et al. concluded that the replacement of an upper miniplate by a microplate in the management of mandibular fractures is stable and adequately efficacious to withstand the masticatory and torsional forces acting in the anterior region of the mandible.
Ahmed et al. recommend the use of microplates for treatment of mandibular fractures. As there is no significant difference in the bite force generated when microplates are used, in comparison with miniplates, and they provide adequate stability to fractured segment, their use may be recommended for routine use. Another important aspect is minimization of metal leaching in the adjacent tissues.
The purpose of this systematic review was to verify the efficiency of microplates either alone or in combination with miniplates for fixation of mandibular fractures in comparison with miniplates.
| Materials and Methods|| |
Key words formulation and databases selection
Electronic databases including PubMed and Cochrane Database of Systematic Reviews, Cochrane central register of controlled trials (CENTRAL), and Wily online library were searched in April 2018 without date or language restrictions using the key words and combinations of these used in the search, which included the following:
(1) 'Mandibular fracture' or 'Lower jaw fracture' or 'Parasymphyseal fracture' or 'Interforaminal mandibular fracture' or 'Mandibular body fracture' or 'Mandibular angle fracture' or 'Mandibular ramus fracture' or 'Mandibular subcondylar fracture'
(2) 'Open reduction' or 'Internal fixation' or 'Direct fixation' or 'Titanium miniplates' or 'Titanium microplates' or 'Miniplates and microplates'
(3) 'Proper reduction' or 'Rigid fixation' or 'Proper occlusion' or 'Biting force' or 'Fracture stability' or 'Plate palpability' or 'Plate dehiscence' or 'Paresthesia'
(4) '#1' and '#2', and '#3'.
Most popular oral and maxillofacial surgery-related journals were manually searched; furthermore, we also searched the gray literature (Google Scholar) and the reference lists of all studies identified as relevant reviews for possible additional studies. Duplicates were discarded. Hard copies of all relevant articles were retrieved after screening the titles and abstracts of each one and assessed for its eligibility. Inclusion criteria and exclusion criteria were determined, and all articles were independently assessed against these criteria. Disagreements concerning the selected studies were resolved by discussion.
Inclusion criteria were clinical studies with adult human participants including randomized controlled trials, controlled clinical trials, and nonrandomized clinical trials, with the aim of assessing the efficacy of microplates alone or in combination with miniplates for internal fixation of mandibular fractures in comparison with the common use of miniplates for internal fixation of mandibular fractures.
The exclusion criteria were review articles, case reports, case series, studies on children with mandibular fractures, and experimental studies on animals or models.
The quality assessment of the selected articles was done with the Jadad scale. The maximum possible score was 13 points using an 11-item instrument (11 questions). This was considered to be good when the score was more than 9 points and poor when the score was equal to or less than 9 points. Three items related directly to the control of bias using the Jadad scale, and the other eight items were not related directly to the control of bias. Items were scored by giving either a score of 1 point for each 'yes' or 0 points for each 'no'. There are no in-between marks. An additional point was given for question 1, if the method to generate the sequence of randomization was described and was appropriate (table of random numbers, computer generated, etc.), but we deduct 1 point if, for question 1, the method to generate the sequence of randomization was described and was inappropriate. Moreover, an additional point was given for question 2 if the method of double blinding was described and was appropriate, but we deduct 1 point for question 2 if the study was described as double blind but the method of blinding was inappropriate.
| Results|| |
The systematic search displayed 761 results from PubMed, Cochrane Library databases, and hand searching. During the primary exclusion, the duplicated references were removed then all studies were screened, analyzing the titles and abstracts of each one. A total of 750 articles were excluded in the screening phase. Overall, 11 articles were assessed for eligibility. Studies that did not meet the aforementioned inclusion criteria were excluded in this phase (n = 7), although these seven studies were concerned with the evaluation of the efficacy of using the microplates for fixation of mandibular fractures, but there were different reasons for their exclusion [Table 1]. At the end of this process, four randomized controlled trials were included in the review for qualitative and quantitative analyses [Figure 1].
Characteristics of the included studies
Four studies,,, were included in this systematic review: three,, were randomized controlled clinical trials and one study was controlled clinical trial. The primary outcome of all studies was biting force measurement and its recovery to be normal or near normal throughout different follow-up visits. Detailed characteristics of the included studies are shown in [Table 2]. In the first study, 20 patients were treated for isolated mandibular fractures of the interforaminal region and randomly divided into two groups: the test group (group A: 10 patients) was managed by open reduction and internal fixation (ORIF) using a combination of 1.2 mm microplate at subapical region and 2.0 mm miniplate at the inferior border of the mandible, whereas the control group (group B: 10 patients) was managed by ORIF using two 2.0 mm miniplates.
In the second study of Kumar et al., 10 patients with mandibular fractures were managed by ORIF using the microplates, whereas the control group consisted of 10 normal individuals for comparison with the study group through bite force measurement and determine the time at which the bite forces reach a functional range. In the third study, Ahmed et al. randomly divided 40 patients with mandibular (symphyseal/parasymphyseal/body) fractures into two groups: group I consisted of 20 patients and managed by ORIF using 2.0 mm miniplates, and group II consisted of 20 patients managed by ORIF using 1.5 mm microplates. This was in addition to a third control group that consisted of 30 healthy volunteers to measure their normal functional range of the bite force. The last study included in this systematic review was conducted by Anand et al. on 20 patients with mandibular fractures in the interforaminal region and randomly divided into two groups: group A consisted of 10 patients and were managed by ORIF using a combination of one microplate (1.2-mm screw diameter and plate thickness of 0.55 mm) placed subapically and one miniplate (2.0-mm screw diameter and plate thickness of 0.9 mm) placed at the inferior border, whereas group B consisted of 10 patients and were managed by ORIF using two 2.0 mm miniplates. Moreover, 10 healthy individuals were included in control group C to determine the normal range of the biting force in comparison with the study groups to evaluate their extent of recovery. All studies did not use postoperative maxillomandibular fixation, except Anand et al., who mentioned that mandibulomaxillary fixation was placed for ∼2 weeks in cases associated with condylar fractures. Moreover, all patients did not complain of any associated fractures other than the mandibular fractures, which were simple and minimally displaced.
Quality assessment of the included articles
After evaluating the articles included in this systematic review with the Jadad scale, two articles represented a good score and the other two articles represented poor score [Table 3].
|Table 3: Quality assessment of the included articles with the Jadad scale|
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Biting force measurement was the primary outcome of all studies included in this systematic review. Different bite force recorders (but of the same idea) were used to measure the bite force in Newton (N) in two studies, and in kilopound (kp) or kilogram force (kgf) in the other two groups of healthy volunteers to measure the normal biting force, which may be different among different races, but the population of all the included studies was the Indian people [Table 4].
Gupta et al. found a statistically significant increase in the bite force recorded in the test groups from the preoperative to the postoperative follow-up visits, but statistically nonsignificant difference was found between both the microplate group and the miniplate group.
Kumar et al. found that the rate of recovery of maximum bite force in a patient with a treated mandible fracture by microplates was steady over a 6-week period but not completely normal; hence, the week 1, bite forces of the patient group accounted for only 23% of the control group values. These values rose to 30% in week 2, 40% in week 3, 44% in week 4, 58% in week 5, and 66% at the end of week 6. Ahmed et al. found that the bite forces progressively increased in each study group, and their comparative value remained insignificant throughout the phase of recovery. However, by the end of the sixth week, patients in either group regained 60% in molar region and 75% in anterior region. Anand et al. recorded the bite force between the study groups at different regions at different time intervals. It showed increase in the bite force values, from postoperative day 1 to third month in both the groups, which was significant. However, bite force comparison between the study groups showed no significant difference.
Gupta et al. reported that infection was seen in one (10%) patient in each group as the patient reported swelling and pus discharge on the fracture side which was managed and on exploration the fracture had united and the infection was resolved in the two patients and no further complication was reported. Kumar et al. were concerned only with their primary outcome to measure the biting force for patients with mandibular fracture and treated by ORIF using microplates and compared with the biting force of the normal individuals and to determine the time taken for the bite forces to return to the normal functional range. Kumar et al. did not mention any secondary outcome or any associated complications. Ahmed et al. reported that the overall complications were recorded in five (12.5%) patients in both the study groups. One patient required revision surgery, two patients had occlusal derangement, one had abscess in the fracture line, and one patient complained of dehiscence. The disturbed occlusion was seen in the microplate group and none in the miniplate group. In addition, one case of hypesthesia was seen in the microplate group and none in the miniplate group. Anand et al. reported that the assessment of the fracture stability showed favorable results, whereas one (10%) patient from each study group had mild occlusal derangement; moreover, two patients in the miniplate group developed infection.
| Discussion|| |
Earlier microplates were used in non-stress-bearing areas such as midface, but recent experimental and clinical studies have shown that microplates can be used sufficiently in the stress-bearing areas of the mandible,.
Bite force is considered as one of the indicators of the functional state of the masticatory system that results from the action of jaw elevator muscles modified by the craniomandibular biomechanics. The maximum occlusal force is reduced with fractures within the masticatory system, so the measurement of the biting force was used to compare between different plating systems in the management of mandibular fractures and to determine the rate of recovery of the biting force to the normal functional range,.
Four studies were included in this review; all of them have shown progressive increase of the biting force in the study groups without significant difference between the microplate and miniplate groups. At 6-week postoperative follow-up visit, the biting force was ∼60–75% of the control group, whereas Gupta et al. and Anand et al. have shown that the biting force reached the normal functional range at 3 and 6 months follow-up visits. This was in agreement with Kumar et al.. The maximum voluntary bite force represents the greatest force an individual could voluntarily generate. The amount of force used during functional activities is probably much less. Hence, the fixation requirements based on the maximum voluntary bite force in noninjured participants may be inflated, and this is may be the reason the semirigid fixation was successful so we can use microplates as aform of semirigid fixation successfully,.
Complications of the included studies were recorded within the acceptable level associated with the traditional techniques of ORIF, without significant difference between both the microplate and miniplate groups. Although the cost is the main disadvantage of titanium microplates, they have better mechanical properties and smaller dimension and less cost than resorbable plates. Cost-effectiveness studies should consider all the advantages of microplates regarding their smaller size, ease of application, greater malleability, less tissue stripping or nerve injury, and then little complications or need for second surgery,,.
Different limiting factors were present in this review, such as the diversity of the bite force measuring devices in addition to different measuring unit of the bite force; Gupta et al. and Ahmed et al. were measuring the biting force in kilogram force (kgf), whereas Kumar et al. and Anand et al. were measuring the biting force in Newton (N). Another limiting factor was the size of the microplate and whether used alone for fixation or used in a combination with a miniplate. Gupta et al. and Anand et al. used one 1.2 mm microplate in a combination with one 2.0 mm miniplate in comparison with two 2.0 mm miniplates, whereas Ahmed et al. used two 1.5 mm microplates in comparison with two 2.0 mm miniplates, and also Kumar et al. did not define the size of the microplates.
The site of the mandibular fracture was another limiting factor. Gupta et al. and Anand et al. have managed cases with isolated mandibular interforaminal fracture, except seven patients of 20 patients in the study of Anand et al., who were associated with subcondylar fracture and kept in intermaxillary fixation for 2 weeks and consequently the biting magnitude was affected. The patients managed by Ahmed et al. had isolated mandibular fracture either symphyseal, parasymphyseal, or body fracture, whereas Kumar et al. did not define specific site in the mandible. There was a great diversity in the protocol of the follow-up visits in the included studies, as seen in [Table 1]; in addition, the whole period of follow-up was too short in the two studies,, as 6 weeks were not enough for complete recovery to determine the time needed for patients to reach the normal functional range of the biting force.
Four articles in this systematic review are a limited number of articles, all of which were of small sample size, in addition to the individual variation in the biting force; all these limiting factors increased the heterogeneity in the review and did not allow doing a meta-analysis. Numerous future studies are needed to investigate the efficacy of using the microplates for mandibular fractures to determine their indications and contraindications and these studies should have some form of standardization regarding size of microplates, site of the fracture, presence of associated fractures, using an international bite force recorder, and the same follow-up protocol.
| Conclusion|| |
In light of the included studies, microplates have high holding power and were efficacious for internal fixation of simple, minimally displaced, isolated mandibular fractures, but there is still no sufficient evidence to support this information safely, so numerous future studies with sound methodology and larger sample size are needed to evaluate their use in the other forms of mandibular fractures.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]