Open versus closed reduction: comminuted mandibular fractures

The purpose of the study was to review the literature regarding the evolution of current thoughts on management of comminuted mandibular fractures (CMFs).

An electronic search in PubMed was undertaken in May 2012. The titles and abstracts from these results were read to identify studies within the selection criteria. Eligibility criteria included studies published in English or German reporting clinical series of CMFs.

The search strategy initially identified 409 studies. Fifteen studies were identified without repetition within the selection criteria. One case report article showing significance in the development of treatment techniques was included. Additional hand-searching yielded five additional papers. Thus, a total of 21 studies were included.

Open reduction and internal fixation (ORIF) in cases of CMFs are indicated in (a) severe injuries with significant displacement to allow restoration of pretraumatic anatomic relationships, (b) in the edentulous and semi-dentate patient, who may benefit from ORIF of CMFs when stable occlusal relationships are absent, and (c) in cases with multiple fractures of the midface, in which the mandible has to serve as a guide to reposition the midfacial bones. However, there is still a place for closed reduction/conservative treatment (CTR). ORIF in CMFs is not indicated in cases of minimally displaced comminuted fractures that could easily and adequately be treated with CTR. If the surgical team is not well versed in the nuances of rigid internal fixation, or the necessary equipment is not available, it is far better to do simple CTR. However, it would be more reasonable to refer the patient to a hospital that can provide means of ORIF in cases of clear indication of its use in CMFs. In cases where ORIF is indicated, stabilization by compression or any other form of load-sharing osteosynthesis is obviously contraindicated because small fragments cannot be compressed and are not capable of sharing loads. Thus, the ORIF of CMFs is best performed using load-bearing osteosynthesis; most experience has been gained with 2.7-mm reconstruction plates. External pin fixation could be used in cases when there is so much comminution, soft tissue disruption (mostly gunshot wounds), and there are inadequate teeth on either side of the comminuted fracture to control the spatial relationship of the remaining mandibular fragments with maxillomandibular fixation (MMF).