Triological Society Best Practice
Is fixation of mandible fractures urgent?†
The authors have no financial disclosures for this article.
The authors have no conflicts of interest to disclose.
Mandible fractures have been studied extensively, but controversy remains over the urgency of repair. There are conflicting reports on this topic with some recommending immediate fixation, or at least within the first 72 hours, whereas others claim that repairs as late as 5 days postinjury do just as well.1–3 There are a number of considerations that influence timing of intervention, such as associated injuries, which can preclude aggressive surgical manipulation. However, there is a transition period when the sense of “urgency” becomes more germane. Should a closed reduction with mandibular-maxillary fixation (MMF) be promptly performed at the beside of the intensive care unit patient? Alternatively, can they be conveniently seen in the office and scheduled for elective surgery within a week or 2? Intuitively, delayed repair can be associated with compromised nutrition, poor hygiene, inflammation, scarring within the fracture, and even contamination. On the other hand, facial swelling can also subside and facilitate exposure. Most importantly, however, is whether or not the final outcomes are impacted in terms of union and occlusion.
Several articles support earlier repair. Maloney et al.3 described their protocol for mandible fracture repair in which 52 patients were treated promptly. Sixty-two percent of their patients had their reduction/fixation within the first 24 hours, and 87% within the first 72 hours. From this group, only one patient had an infectious complication, who also had a host of other systemic comorbidities. They claim that their success with these patients, in particular their low infection rate, was in part due to the timing of repair. Although their treatment algorithm is successful, there was not a comparison group in which treatment was delayed.
Biller and colleagues4 retrospectively reviewed two groups of patients: those repaired between days 0 to 3 postinjury, and those repaired 4 days and beyond. Eighty-four patients met inclusion criteria and were grouped by day to repair. They found no difference in rate of infection and the only predictor was the history of substance abuse. They did reveal, however, a significantly greater rate of technical complications in the delayed group (P < .05). These “technical complications” included weakness to the marginal mandibular nerve, exposure of the plate, neuropathic pain, and malocclusion. The early group had no complications, whereas the delayed group had 10 (18.9%) patients with these problems. They did not look at the incidence of substance abuse for these groups separately. Moreover, the severity and complexity of fractures were not addressed for the two patient groups, which may have introduced a bias. They recommend an earlier repair of mandible fracture based on the greater incidence of these “technical complications” and stress the need to be even more vigilant when delay is unavoidable.
Other studies have concluded that a delay in repair did not impact outcomes.1–3 Czerwinski et al.1 performed a retrospective study of 177 patients and divided them into two groups, those repaired within 72 hours and those after 72 hours. They found no difference in outcomes but did note an association with infection and substance abuse (P < .05). Interestingly, there was no difference in the rate of infection when comparing those who received antibiotics with those who did not.
Hermund et al.5 performed a literature review regarding early versus delayed repair. They found four studies that showed no difference in complication rate between early or delayed repair. There were no retrospective studies, and the conclusion of the article was that there is no evidence to support either early or delayed repair.
Table I illustrates the summary findings of each reference. Only one study showed a significant association with timing. Substance abuse included tobacco, alcohol, or other drug use. Complications included technical and/or infectious complications.
Table I. Summary of Referenced Papers
|Biller||0–3||3 (9.7%)||28 (90.3%)||17 (54.8%)||Fewer technical complications with early repair|
|4+||18 (34%)||35 (66%)||38 (71.7%)|
|Czerwinski||0–3||12 (48%)||79 (52%)||NR||No significance|
|4+||13 (52%)||73 (48%)||NR|
|Furr||0||5 (29.4%)||94 (38.8%)||NR|| |
|1–4||7 (41.2%)||99 (40.9%)||NR||No significance|
|5+||5 (29.4%)||49 (20.3%)||NR|
|Maloney||0–3||1 (2.2%)||44 (97.8%)||29 (64.4%)||No significance|
|4+||0 (0.0%)||7 (100%)||5 (71.4%)|
Delay in surgical repair of mandible fractures may be unavoidable. It is not always due to significant associated injuries (cervical spine, intracranial injury, etc.). Compliance in this population is frequently unpredictable, and many patients may seek medical care only after a delay (particularly if their analgesics have been depleted). Ideally, a randomized study would allow an accurate comparison of outcomes but this is unlikely to be achieved. At present, there is no evidence confirming that immediate repair is necessary for better outcomes with mandible fractures.
Delay in repair can be associated with technical challenges and complications. A more vigilant debridement, reduction, and fixation are all warranted. Delay up to 5 days after injury has not been shown to compromise outcomes in terms of bony union and occlusion. Substance abuse appears to be associated with a greater rate of infection.
LEVEL OF EVIDENCE
In this series there are four level 4 article and one level 3a article.