Management of Mandibular

A n g l e Fr a c t u re
Daniel Cameron Braasch, DMD,
A. Omar Abubaker, DMD, PhD*

KEYWORDS
 Angle fracture  Mandible  Biomechanics  Miniplate  Treatment

KEY POINTS
 The angle fracture is one of the most common fractures of the mandible and is associated with the
highest complication rates.
 Treatment of angle fractures has incorporated better understanding of the biomechanics of the
mandible, the evolution in the patterns, and types of fixation and advances in surgical techniques
treating these fractures.
 Several techniques are acceptable to treat mandibular fractures, and the most common technique
for isolated mandibular angle fracture is a single miniplate placed at the superior border.
 Routine use of postoperative antibiotics and removal of teeth in line of fracture is less advocated
and best judged on a case-by-case basis.

INTRODUCTION accidents. Other potential causes of mandibular

fractures include falls, sporting or work-related
Fractures through the angle of the mandible are accidents, gunshot wounds, and pathology. Frac-
one of the most common facial fractures. The tures occur more frequently in the male population
management of such fractures has been contro- and are often associated with alcohol consump-
versial, however. This controversy is related to tion.2 Although most fractures occur as a result
the anatomic relations and complex biomechan- of a traumatic event, some may occur due to
ical aspects of the mandibular angle. The debate preexisting pathology. Pathologic fractures result
has become even more heated since the evolution from such conditions as osteoradionecrosis,
of rigid fixation and the ability to provide adequate bisphosphonates-related osteonecrosis, and
stability of the fractured segments. This article pro- benign or malignant tumors or cysts that weaken
vides an overview of the special anatomic and the structure of the angle to the point where a frac-
biomechanical features of the mandibular angle ture occurs from minimal or no trauma (Fig. 1).
and their impact on the management of these
fractures.
CLASSIFICATION AND PATTERNS OF
ETIOLOGY MANDIBULAR ANGLE FRACTURES
Angle fractures are the most common mandibular The mandibular angle is best described as an
fracture, accounting for 30% of all mandibular frac- anatomic region rather than a precise anatomic
oralmaxsurgery.theclinics.com

tures.1 The majority of such fractures occur as a location. This region is designated as a triangular
result of interpersonal violence or motor vehicle area with the superior edge being the junction of

Dr Braasch is currently in private practice in 33 Trafalgar Square, Nashua, NH 03603.

Disclosures: The authors have nothing to disclose.
Department of Oral and Maxillofacial Surgery, School of Dentistry, VCU Medical Center, Virginia Common-
wealth University, 521 North 11th Street, PO Box 980566, Richmond, VA 23298-0566, USA
* Corresponding author.
E-mail address: [email protected]

Oral Maxillofacial Surg Clin N Am 25 (2013) 591–600

http://dx.doi.org/10.1016/j.coms.2013.07.007
1042-3699/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
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592 Braasch & Abubaker

such as gunshot wounds and high-speed motor

vehicles accidents.
The degree of fracture separation is another ba-
sis for classification. Complete fractures occur
when there is disruption of both the medial and
lateral cortices (Fig. 3). Greenstick fractures,
which are rare, occur when there is disturbance
of only one cortex.
Mandibular angle fractures can also be
described as favorable or unfavorable. A favorable
Fig. 1. Pathologic fracture through the left angle due fracture occurs when the masseter and medial
to osteoradionecrosis. pterygoid muscle action on the proximal and distal
segments of the fracture help to reduce it. The
more common unfavorable fracture involves sepa-
the horizontal body and vertical ramus, usually ration of the proximal and distal segments due to
where the third molar is or was located. The ante- muscle pull. An unfavorable fracture is further
rior border of the masseter muscle forms the ante- labeled as horizontally or vertically unfavorable.
rior border and the posterior border of the triangle During a horizontally unfavorable fracture, the ac-
is formed by an oblique line extending from the tion of the masseter and medial pterygoid muscles
third molar region to the posterior superior attach- distracts the proximal segment superiorly while
ment of the masseter muscle (Fig. 2).3 the suprahyoid muscles act to distract the distal
Fractures through the mandibular angle can be segment inferiorly (Figs. 4 and 5). A vertically
classified in a variety of ways. First, they can be unfavorable fracture occurs when the fracture
described as either closed or open fractures. A pattern allows for the distal segment to be pulled
closed fracture does not communicate to the medially by the medial pterygoid muscle (see
outside environment; whereas an open fracture is Fig. 3; Fig. 6).
partially or completely exposed intraorally or Mandibular angle fractures can occur in combi-
extraorally through the overlying tissues. Extraoral nation with many other facial or mandibular frac-
open fractures rarely occur except in high-velocity tures. When angle fractures occur in combination
or penetrating injuries. Intraoral open fractures are with other mandibular fractures, the most common
more common due to tearing of the gingiva over- secondary fracture site is at the contralateral para-
lying the angle at its superior border. Connection symphysis.4 The presence of bilateral mandibular
of the fracture to the mouth through the peri- angle fractures is rare but, when present, requires
odontal ligament also creates an open fracture. special attention because the dentate segment
Angle fractures can also be classified as simple can become displaced posteriorly, resulting in
or comminuted. Simple fractures involve only a
single break through the bone whereas commi-
nuted fractures display multiple breaks. The latter
are more often caused by high impact trauma,

Fig. 2. Shaded area designates the anatomic region of Fig. 3. Complete fracture through the mandibular
the mandibular angle. angle.

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 Management of Mandibular Angle Fracture 593

Fig. 4. Unfavorable fracture is created by the pull of

the masseter (lateral) and medial pterygoid (medial)
superiorly (red arrow) and suprahyoid muscles inferi-
orly (blue arrow).
Fig. 6. Separation at the superior border demon-
strated by the red arrows. Compression at the inferior
airway compromise. Close observation of patients
border indicated by blue arrows.
with these type of fractures is needed to prevent
airway collapse.
Based on these considerations, Spiessel rec-
BIOMECHANICAL CONSIDERATIONS ommended the use of an arch bar when the frac-
ture is within the dental arch.6 The arch bar acts
Understanding the biomechanics of mandibular to prevent fracture displacement at the superior
angle fractures helps clinicians chose their proper border. Along the alveolar ridge, when the fracture
management. Such biomechanics are based on is beyond the dental arch, he recommended the
the mandible acting as a class 3 lever. In this use of a 2-hole tension band plate. Later,
model, the muscles attached to the mandible Schmoker and Spiessl7 introduced another
create a tensile force at the superior border and method of neutralizing the alveolar tensile forces
a compressive force at the inferior border. A by using an eccentric dynamic compression plate
zone of no tension or compression is found at the inferior border, where the design of the holes
between the superior and inferior borders. This in the plate generated eccentric compression at
zone is termed, the neutral zone. The anatomic the superior border similar to that of a tension
location of the tensile zone corresponds to the band. This was expected to result in what was
mandibular alveolus and external oblique ridge.
The compressive zone is located at the inferior
border of the mandible.5 The neutral zone is found
at the level of the inferior alveolar nerve. Figs. 7
and 8 demonstrate the superior tension zone and
inferior compression zone, where separation at
the superior border and reduction at the inferior
border occur during a mandibular angle fracture
under function.

Fig. 7. Vertically unfavorable fracture demonstrating

the potential medial displacement of the proximal
segment due to the pull of the medial and lateral
pterygoid muscles (red arrows) compared with the
Fig. 5. Unfavorable left mandibular angle fracture. lesser lateral pull of the masseter (blue arrow).

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594 Braasch & Abubaker

converting a closed fracture to an open fracture,

especially when a transoral approach is not
used. Another disadvantage to removing an
impacted tooth in the fracture site is the potential
need to remove bone to facilitate its extraction.
This may compromise the buttressing of bone
and result in inadequate bone to place the tension
band plate at the superior border (Figs. 9 and 10).

DIAGNOSIS
Physical Examination
With the routine use of CT scans in emergency de-
Fig. 8. Demonstration of the superior tension zone, partments, the importance of the physical exami-
middle neutral zone, and inferior compression zone. nation is often overlooked. Extraoral examination
Arrows showing zone of tension superiorly and should begin with a visual inspection. Swelling,
zone of compression inferiorly. ecchymosis, and step deformity and tenderness
to palpation at the inferior border may be a sign
of an angle fracture.1 A thorough cranial nerve
described as buttressing away from the plate. This examination should be routine practice in any
technique, although initially accepted, never physical examination, with special attention to
gained popular use, likely due to the technical dif- potential changes in the third division of the fifth
ficulty. In the 1970s, however, Michelet and col- cranial nerve. Fractures through the mandibular
leagues8 and, later, Champy and colleagues9 angle, especially when there is some degree of
thoroughly studied the use of a minplate along displacement, are likely to cause hypoesthesia,
the superior border of the mandible. The plate anesthesia, or dysesthesia of inferior alveolar
was placed transorally and secured with mono- nerve. Rarely is the facial nerve (cranial nerve VII)
cortical screws, thus minimizing possible risk to injured with angle fractures, but this can occur
the teeth and inferior alveolar nerve. Subsequently, with penetrating trauma. It is imperative to docu-
several additional biomechanical and clinical ment these findings in the preoperative evaluation
studies have shown the effectiveness of this as a baseline for postoperative monitoring.
technique. Intraoral examination can reveal ecchymosis,
gingival lacerations, and bleeding in the posterior
TEETH IN THE LINE OF FRACTURE buccal and lingual vestibules. Evaluation of the
The presence of impacted third molars has been occlusion may show a malocclusion, with prema-
shown to increase the risk of angle fractures.10–12 ture tooth contact on the fractured side and an
This increased risk is related to the decreased open bite on the contralateral side. In cases of
amount of bone, resulting in a reduced resistance bilateral mandibular angle fractures, an anterior
to traumatic forces. The depth and angulation of open bite and posterior displacement of the
impaction is considered by most authors to not tooth-bearing segment can occur.
be associated with an increased risk of fracture.11
Radiographic Examination
Management of teeth in line of fracture has also
often been examined in relation to the incidence of When using plain films, at least 2 views of the
complications with mandibular angle fracture. mandible should be obtained. The radiographs
Although one study showed that there is an in-
creased risk of infection when teeth are retained
in the line of fracture, the difference was not stati-
cally significant.13 Accordingly, the mere presence
of a tooth in the fracture line does not necessitate
its removal. The tooth should be removed, how-
ever, if it prevents reduction of the fracture, there
is infection related to the tooth, or there is patho-
logy associated with it. The disadvantage of
routine removal of impacted or even erupted third
molars in a mandibular angle fracture is related to
the possibility of creating a soft tissue deficit at the Fig. 9. Fracture through the angle with fracture of
extraction site. Furthermore, there is a risk of tooth #32.

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 Management of Mandibular Angle Fracture 595

band at the angle. After use of closed reduction,

an immediate postoperative panoramic radio-
graph should always be obtained to confirm the
proper reduction of the segments.
Maxillomandibular fixation can also be used
alone or in combination with external pin fixation
when there is a comminuted fracture with several
small bony segments that cannot be stabilized
using standard plate and screw fixation.

Fig. 10. Postoperative panoramic radiograph showing

extraction of tooth #32 and placement of a superior Open Reduction and Internal Fixation
border plate at the right mandibular angle.
With the exception of these situations (discussed
previously), open reduction and internal fixation
should be 90 from each other to ensure proper are used to treat the majority of mandibular angle
evaluation. The use of plain films has fallen out of fractures. The variations in open reduction and
favor due to the accessibility of CT scans in most internal fixation of the mandibular angle fracture
hospital emergency departments. Axial CT scans stem from the surgical approach to the fractures
with sagittal and coronal reconstructions provide and the method of rigid fixation. It is easy to under-
excellent visualization of all dimensions of the frac- stand these variations in treatment when viewed
ture and are becoming the gold standard. In the based on an understanding of fracture biome-
office setting and as an initial screening tool, a chanics and rigid fixation.
panoramic radiograph is still a valuable tool, espe-
cially when considering the ease of obtaining it, the Approaches
low cost, and minimal radiation exposure to
patients. Generally speaking, either a transoral or transfacial
(extraoral) approach is used to access the frac-
tured site. The recent increase in the popularity,
PRINCIPLES OF TREATMENT OF MANDIBULAR however, of using a superior border plate tech-
ANGLE FRACTURES nique has resulted in the use of a transoral
Although there has been considerable evolution in approach becoming common. The transoral
the treatment of mandibular angle fractures over approach uses an incision over the external obli-
the past 3 decades, there is still wide acceptance que ridge that is carried superiorly along the
of the both closed and open treatment of these ascending ramus and anteriorly to the first molar.
fractures. These alternatives are dictated by the A 3-mm to 5-mm cuff of unattached tissue is left
nature of the fracture, patient age and medical below the mucogingival junction to facilitate
and psychological status, cost, and occasionally closure. This design allows complete access to
surgeon preference and training. Thus, the initial the lateral and superior aspect of the mandible at
discussion is focused on these 2 types of treat- the angle. If the Champy technique is planned,
ment, followed by a more detailed discussion of the incision is modified and carried slightly medial
the open treatment. to the external oblique ridge, which allows better
access to the retromolar area. Care must be taken
to maintain a subperiosteal dissection to ensure
Closed Treatment with Maxillomandibular
protection of the lingual nerve.
Fixation
When access to the inferior border is needed, a
Closed reduction for mandibular angle fractures submandibular approach is required. This ap-
can only be used with favorable fracture patterns. proach provides excellent access to the inferior
In favorable fractures, the elevator muscles at the border but it carries the risk of damage to the facial
angle of the mandible are less likely to cause the nerve and scarring. Posterior to the facial artery
proximal segment to rotate superiorly and ante- and vein, the course of the marginal mandibular
riorly when the segment is not securely fixed to branch of the facial nerve is found below the infe-
the dentate part of the mandible. In such cases, rior border of the mandible in 19% to 53% of the
closed reduction is generally achieved with fixa- time. The nerve can run as far as 1.2 cm below
tion screws. The use of arch bars provides no the inferior border of the mandible so the planned
added stability of the proximal segment because, incision should be at least 2 cm below the inferior
unlike in dentate portions of the mandible, an border of the mandible to prevent it being
arch bar is unable to provide a superior tension injured.14,15

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596 Braasch & Abubaker

Internal Fixation there are several other treatments options that can
be used.
Historically, a variety of techniques have been
A single plate can be placed at the superior
used for internal fixation of mandibular angle frac-
border along the lateral aspect of the mandible
tures. These techniques include wire osteosynthe-
to act as a tension band.8,9 This has a low compli-
sis, a single superior border plate, a single inferior
cation rate of 12% to 16%.18,19 Several studies
border plate (2.3 or 2.7 mm), 2 plates (1 at the
have shown no increased risk of complications
superior border and 1 at the inferior border), or a
when comparing the use of 1 plate with 2 plates
lag screw. Since introduction of the technique for
whereas other studies have actually shown a
fixation of mandibular angle fractures described
decreased rate of complications with the use of 1
by Michelet and colleagues,8 however, there has
superiorly placed noncompression plate.20–23
been a great deal of controversy regarding the
The superior border and Champy techniques
most appropriate method.
traditionally use a 2.0-mm plate to provide fixation.
The treatment of mandibular angle fractures is
The use of a more malleable plate would allow for
based on the theory of providing a superior ten-
easier plate adaptation, potentially lower rates of
sion band and an inferior compression band.
dehiscence, and result in shorter operating times.
Fig. 7 demonstrates the displacement at the su-
Potter and Ellis24 showed a complication rate of
perior border that occurs in an angle fracture.
only 15% when a 1.3-mm miniplate was used,
At the angle, displacing forces are present at
but the incidence of plate fracture was high. Micro-
the superior border, which is perpendicular to
plates were shown to successfully treat angle frac-
the line of fracture. Placement of a superior
tures, but this required maxillomandibular fixation
border plate can provide resistance to such dis-
for 6 weeks after open reduction.4,25 As a result,
placing forces.
a 2.0 miniplate is recommended by most investi-
The method of fixation must provide adequate
gators. This plate still allows for easy adaptation
stability at the fracture site to allow for proper heal-
but provides an adequate amount of stability to
ing and a low complication rate. The different
allow for proper healing (Figs. 11 and 12).
methods and techniques of fixation for isolated
mandibular angle fractures are discussed. When Two-Plate Technique
there are additional associated fractures in the
mandible, in addition to angle fractures, the treat- The 2-plate technique involves placement of 1
ment may best be adjusted to minimize possible plate at the superior border to act as a tension
complications. Recently, Ellis16 showed that when band and 1 plate at the inferior border to act as a
there is a fracture of the angle and an associated compression band. In vitro studies have demon-
body or symphysis fractures, at least one of these strated that 2-plate fixation is a more stable
fractures must be rigidity fixed to minimize compli- method, with lower stress at the fracture site
cations of these fractures. Such rigid fixation may compared with a single superior border plate
include locking/nonlocking reconstruction bone placed in the Champy style.26 Choi showed a
plates, multiple bone plates at the fracture site, sin- low complication rate with the 2 noncompression
gle strong nonreconstruction bone plates, or multi- miniplate technique, reporting only 4 complica-
ple lag screws. tions (2 postoperative infections and 2 occlusal
disturbances) in 40 patients.26,27 Conversely, in
Single Plate: Superior Border
The position and number of plates to fix a mandib-
ular angle fracture have been extensively re-
searched and reported in the literature. Most
investigators agree on the use of a single non-
compression miniplate at the superior border for
treatment of noncomminuted mandibular angle
fractures. Gear and colleagues17 looked at the
current practice of North American and European
AO/ISF (Arbeitsgemeinschaft für Osteosynthese-
fragen/Association for the Study of Internal Fixa-
tion) faculty and showed that the most common
practice (51% of surveyed faculty) was the place-
ment of a single superior border plate. Although
many surgeons have accepted the superior border Fig. 11. Champy superior border plate method
plate as the method of treatment of angle fractures, fixation.

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 Management of Mandibular Angle Fracture 597

Fig. 12. Superior border plate. Fig. 13. Inferior border plate.

1994, Ellis and Walker28 showed the use of two fractures. The 3-D or matrix plate is a straight or
2.0-mm noncompression miniplates had an unac- curved ladder plate that uses monocortical screws
ceptable complication rate of 28%. A prospective to provide stabilization along the lateral aspect of
randomized study by Danda and coworkers29 indi- the mandible. This plate configuration has been
cated no difference in the rate of malocclusion, shown to have similar stability compared with the
infection, and wound dehiscence between a single 2.0 miniplate but superior resistance to out-of-
plate placed with the Champy technique versus 2 plane movements.32 Several in vivo studies have
plates. This suggests that the use of a second shown the success of the 3-D plate for treatment
plate at the inferior border is not necessary for of angle fractures.32–34 In these studies, there
proper fixation and healing. Furthermore, the have been low complication rates, with no reports
placement of the inferior plate increases operating of malunion or nonunion. When complications
time and often requires an extraoral approach, occurred, they included wound dehiscence and
which introduces the risk of facial nerve damage surgical site infection, which did not have a signif-
and scarring. icant impact on healing at the fracture site.33,34

Single Plate: Inferior Border Bioresorbable Plates

The use of a single plate at the inferior border often There are few studies involving the use of bio-
requires an extraoral approach to allow for proper resorbable plates in the treatment of mandibular
placement. A larger, 2.3-mm plate or a reconstruc- angle fractures. In vitro studies have shown no sta-
tion plate is used to provide more rigid fixation in tistically significant difference in breaking and
the compression zone. With the success and displacement forces when comparing 2.0-mm
ease of access using a superior border plate, the titanium plates and resorbable plates.35,36 Limited
use of inferior border plates has declined. An infe- studies with small sample sizes have shown that
rior border plate is still indicated, however, when bioresorbable plates can be used to successfully
there is a lack of adequate bone at the superior treat angle fractures, with no reports of malunion
border, which may occur with comminuted frac- or nonunion. These studies also demonstrated
tures, previously failed hardware, or pathologic a low complication rate with bioresorbable
fractures (Fig. 13). plates.37–39 Although these studies have shown
the efficacy of bioresorbable plates, more studies
Lag Screw Fixation are required before routine use is recommended.
The major advantages of lag screws are the high
degree of compression at the fracture site, supe- ANTIBIOTICS FOR TREATMENT OF
rior stability, decreased equipment cost, and MANDIBULAR FRACTURES
reduced operating time.30,31 Due to the technical
The use of preoperative antibiotics in the treatment
difficulty of lag screw fixation at the angle, this
of mandibular angle fractures is an accepted prac-
method has not gained popular use.
tice by a majority of surgeons. The use of post-
operative antibiotics, however, continues to be
3-D/Matrix Plate
debated. There have been several studies evalu-
Recently, a new plate configuration has been intro- ating the incidence of infection in mandibular
duced for the treatment of mandibular angle fractures treated with postoperative antibiotics

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598 Braasch & Abubaker

compared with those treated without the use of

postoperative antibiotics. Prospective, random-
ized studies have shown no difference in the inci-
dence of infection in mandibular fracture patients
treated with postoperative penicillin versus no
postoperative antibiotics.40,41 Other studies have
shown similar results with different classes of anti-
biotics.42,43 To date, there continues to be no good
evidence in the literature to support the use of
long-term postoperative antibiotics.
Fig. 14. Hardware failure and malunion of the left
angle.
COMPLICATIONS OF MANDIBULAR ANGLE
FRACTURES
The reported incidence of minor and major com-
Postoperative complications associated with plications in the literature varies widely, but minor
mandible fractures are most common in the angle complications constitute the majority.20 Minor
region. The variety of reported complications is complication, such as localized infections, wound
most likely due to variations in the method of fixa- dehiscence, hardware exposure, and plate loos-
tion, patient-related factors, and how these 2 vari- ening, are frequently related to each other. These
ables interact with the complex biomechanics of complications are generally managed by removal
the mandibular angle. of the loose screws and plate. When they occur
Although prospective randomized studies on in the early postoperative period, however, they
complications of mandibular angle fractures are can often be managed by placing the patient on
scarce, there is an emerging consensus from the oral antibiotics and chlorhexidine rinses. In addi-
retrospective studies, clinical review articles, and tion, maxillomandibular fixation can be used to
the meta-analyses on this topic.3,18,19,23,44–52 further stabilize the fracture until healing occurs.
This consensus involves lower complications rates If swelling or drainage continues after the healing
with the use of noncompression, moncortical, period is complete, the screws and plate then
single-plate fixation placed at the superior border can be removed under local anesthesia in the
of the mandible. Although the use of 3-D grid office.
plates and the locking miniplates have also shown Major complications are uncommon after treat-
good clinical results with low complication rates, ment of mandibular angle fractures, especially
there are too few clinical studies evaluating the with the use of single miniplate fixation. These
use of these plates.34 The use of biodegradable complications are more common with the use of
plates for fixation of mandibular angle fractures 2 miniplates, extraoral placement, and use of an
has been shown to be a stable method of fixation inferior border plate and bicortical screws. The
but may require the use of additional means of fix- rate of major complications in one study consti-
ation to provide adequate stability of the fractured tuted 28% of all complications of mandibular angle
segments.53 Finally, the use of a reconstruction fractures.19 Treatment of major complications
plate for fixation of comminuted angle fractures varies depending on the nature of the complica-
still represents the optimal choice for such tion. Potential treatment options include simple
fractures. removal of the existing hardware and débridement
Postoperative complications of mandibular of the necrotic and infected bone. More extensive
angle fractures are often divided into minor and treatment may be required, however, including
major complications. Minor complications can be
managed in the office, without the need for hospi-
talization or operating room procedures. Minor
complications include localized wound infections,
wound dehiscence, loosening of the fixation
screws or plate, and fracture of the plate. Major
complications after angle fractures are less com-
mon but often result in hospitalization and addi-
tional procedures. These complications include
severe infections requiring incision and drainage,
malocclusion, nonunion, malunion, nerve injury,
and extensive wound débridement with or without Fig. 15. Removal of the failed hardware and place-
bone grafting. ment of new hardware at the inferior border.

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 Management of Mandibular Angle Fracture 599

resetting the fracture and applying new internal fix- 9. Champy M, Lodd JP, Schmitt R, et al. Mandib-
ation. If a large defect remains after débridement, ular osteosynthesis by miniature screwed plates
bone grafting is required (Figs. 14 and 15). via a buccal approach. J Maxillofac Surg 1978;
6:14.
10. Duan DH, Zhang Y. Does the presence of
SUMMARY
mandibular third molars increase the risk of angle
The angle fracture is still one of the most common fracture and simultaneously decrease the risk of
fractures of the mandible and continues to be condylar fracture. Int J Oral Maxillofac Surg
associated with the highest complication rates. 2008;37:25–8.
Treatment of these fractures has witnessed a 11. Meisami T, Sojat A, Sàndor GK, et al. Impacted
significant change over the past 3 decades. This third molars and risk of angle fracture. Int J Oral
change has incorporated better understanding of Maxillofac Surg 2002;31:140–4.
the biomechanics of the mandible, the evolution 12. Máaita J, Alwrikat A. Is the mandibular third molar a
in the patterns and types of fixation, and advances risk factor for mandibular angle fracture? Oral Surg
in surgical techniques treating these fractures. Oral Med Oral Pathol 2000;89:143–6.
Currently, several techniques are considered 13. Ellis E. Outcomes of patients with teeth in the line of
acceptable to treat mandibular fractures; the mandibular angle fractures treated with stable in-
most commonly accepted technique for isolated ternal fixation. J Oral Maxillofac Surg 2002;60:
mandibular angle fracture is a single miniplate 863–5.
placed at the superior border. When angle frac- 14. Dingman RO, Grabb WC. Surgical anatomy of the
tures are associated with another mandibular frac- mandibular ramus of the facial nerve based on
ture, the same technique can be used for the angle the dissection of 100 facial halves. Plast Reconstr
but preferably with rigid fixation of the other frac- Surg Transplant Bull 1962;29:266–72.
ture or fractures. Routine use of postoperative an- 15. Ziarah HA, Atkinson ME. The surgical anatomy of
tibiotics and removal of teeth in line of fracture is the mandibular distribution of the facial nerve. Br
less advocated and best judged on a case-by- J Oral Surg 1981;19(3):159–70.
case basis. 16. Ellis E. Open reduction and internal fixation of com-
bined angle and body/symphysis fractures of the
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