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Comparison between Conventional 2.0 mm Miniplates versus 3-D Plates In Management of Mandibular Fractures

Objective: To compare the outcomes stability, malunion and intra operative time by using 2.0mm conventional miniplates and 3-D plates in management of the anterior mandibular fracture. Materials and Methods: Total 94 patients were included and equally divided in two groups. Fixation of fracture was done by 2.0mm conventional miniplates in Group-A and a single 3D plate in Group-B. Stability, healing and malunion were assessed on follow-up at 1 st week, 6 th week, and 12 week using Chi Square Test. Results: Stability was 91.5% in group-A and 93.6% in group-B. Clinically malunion was 12.8% at 1st week, 14.8% at 2nd week, 14.8% at 8th week in group-A while in group-B, malunion was 8.5% at 1st week, 2nd week and at 8th week. Radiographically, malunion was 12.8% at 1st week, 14.8% at 2nd week, 14.8% at 8th week in group-A while in group-B, malunion was 8.5% at 1stweek, 2nd week and at 8th week. Conclusion: The results of the study concluded that 3-D plating system has advantages over conventional 2 mm miniplates. Original Research Article Kumari et al.; JPRI, 32(37): 83-88, 2020; Article no.JPRI.63824 84


INTRODUCTION
Injuries related to maxillofacial fractures are most probably traumatic in nature, and those are maxillofacial surgeons who treat them well. Literature says the most universal etiological factor related to maxillofacial injuries is road traffic accident (RTA) which shows around 45.3% involvement [1]. Causes other than RTA include falls (42.6%), assaults (0.89%), sport injuries (2.2%), and gunshot wounds (0.89%) [2]. As the mandible shows more central position of face and secondly due to its obvious prominence it gets fractured more often [3]. When it comes to RTA as causative factor, after zygomaticomaxillary complex fracture, the mandibular fracture is the subsequently occurring maxillofacial injury [4]. Mandible is the only freely moveable bone in the facial skeleton, because this bone has shown complex architecture that includes articulation with base of cranium. Because of cherished link with muscles of face, it has always shown strong biomechanical distraction [5]. The incidence of mandibular fracture like condyle 15.27%, coronoid 1.38%, angle 16.66%, body 18.75%, ramus 2.77%, symphysis 12.50% and parasymphysis exhibited the highest incidence 32.63%.
The modalities for the handling or managing fractures of the mandible have been in a constant state of development [5]. As according to champy's law or principle, the rigid and semi rigid fixation technique with miniplating system have gained popularity as a treatment option, but there have been various and numerous management modalities over the years that include splinting of dentoalveolar injuries, circum-mandibular wiring, external pins, transosseous wiring etc [5,6]. The Champy's principles of osteosynthesis has stood the test of time and has proven to be the guiding line to established monocortical fixation the world wide choice for mandibular fractures management [6]. Rigid fixation technique by open reduction has various advantages when we compare it with close reduction technique. Noticeable gaines of rigid fixation are short MMF period or even no MMF, mandibular function that gets early in incorporation, boost in patient happiness and quicker healing [7]. The main drawback in using routine miniplates technique is that it seems deficient tin providing three dimensional stability of the fractured segment, and that too require maxilla-mandibular fixation for a short period [2,4,8]. In recent years the most latest technique in treating maxilla-mandibular surgery is by the three dimensional (3-D) miniplates system, which is also a rigid fixation method [2].
To improve the surgical outcome of fixation with 3D plating system a continuous research is underway to spotlight the dimension, profile, number and mechanics of plate/screw systems [8]. Around 2 decades ago in 1993, a 3-D plate with quadrangular design by Farmad. He did it by uniting two miniplates with interlocking crossbars [2,9]. Stability by three dimensions was the basic concept thought in the development of 3-D plates [10]. And when it comes to stability, it is solely achieved by its configuration not by thickness or length [4,8,10,11]. Nowadays, 3D plate system is one the most standard alternate to conventional plating system, because it has advantage of providing concurrent in the tension and compression zones, and this property make the 3-D plate a time saving method too [8]. In treating maxillofacial trauma, we always desire a reduction method that provides a rapid bone healing and mechanical stability. To stabilize the fracture bone segments, the 3-D plating system requires less number of plates and screws as compared to conventional miniplates [12].

MATERIALS AND METHODS
This is a Comparative cross sectional study with non probability convenience sampling method, conducted at oral and maxillofacial surgery department of Liaquat University of Medical and Health Sciences Jamshoro, Hyderabad from September 2018 to August 2019. The Sample size was calculate by Epi Tools epidemiological www.epitools.ausvet.com,au/. The recommended sample size is 37 in each group, [9] to compensate the loss, we have added 10% for non responded, hence sample size is 47 in each group. Patients were divided by simple randomized method.

Data Collection Procedure
Patients who fulfilled the inclusion criteria and gave written informed written consent for the study were enlisted for this study. Patients were recruited from Out Patient Department (OPD) or through emergency Department of Liaquat University of Medical & Health Sciences Jamshoro/ Hyderabad and were divided in to two group i.e. A and B group(by simple randomized method). Group A (2.0mm conventional miniplates) and Group B (3 D plates).
Diagnosis of mandibular fracture was made through clinical examination, Orthopantomogram (OPG) and P.A view of face and 3D CT scan where indicated.
Under general anesthesia after achieving maximum occlusion with maxillomandibular fixation, muco-periosteal flap was raised intraorally and extra-orally (as per needed by case), after reduction the fracture was fixed with 2.0mm conventional miniplates in Group A and a single 3D plate in Group B (Moin International, Made in Pakistan) with screws of 6mm coritcal/ monocortical otherwise (as per needed by case). Standard IV antibiotics and analgesics were provided to patients of both group as immediate postoperative till 3days, followed by 5 days orally after discharge from hospital.

Data Analysis
The Data was analyzed by statistical software package SPSS version 20.0. The stability, malunion and intraoperative time were assessed by using "Chi Square Test" Qualitative variables were expressed as frequencies and percentages. Descriptive variables like age, gender were calculated. P value less than 0.05 was considered statistically significant.
Malunion was found at immediate postoperative (clinical occlusal discrepancies and radiographicaly step deformity) for 2(4.3%), 6(12.8%) at 1st week, 7 (14.8%) at 2nd week, 7 (14.8%) at 8th week in group A, while in group B, malunion was found for 4(8.5%) patient at immediate postoperative (clinical occlusal discrepancies), 1st week, 2nd week and at 8th week Stratification with respect to treatment group was done to observe effect of these modifiers with  86 6(12.8%) at 1st week, 7 (14.8%) at 2nd week, 7 (14.8%) at 8th week in group A, while in group B, malunion was found for 4(8.5%) patient at immediate postoperative (clinical occlusal discrepancies), 1st week, 2nd week and at 8th espect to treatment group was done to observe effect of these modifiers with stability at 12th week, clinical malunion at 8th week and radiographicaly malunion at 8th week. The results showed that there was significant association of treatment group with c malunion at 8th week (p=0.001), radiographicaly malunion at 8th week (p=0.001) while no significant association was found with stability at 12th week (p=0.694) as presented in Table 3.

DISCUSSION
The main concept of 3-D plating system was initiated by Farmand. These plates derive their stability and mechanical properties because of their focused quadrangular profile, which is dependent on the principle of a quadrangular shape being a geometrically more stable design. It is specifically due to the shape of these plates on which stability and are dependent, rather than plate dimensions and thickness [13,14].
Findings of this study have shown that males were predominantly affected from anterior mandibular fractures as compared to females. Our data is widely supported by various similar studies performed in world like Zafar KJ [15] where he encountered 71.9% cases with male gender. Sadhwani BS [9] also showed male predominance with 64.29% cases. El Nakeeb [16] et al stated that Incidence in males compared with that of females was 4:1.
In this study the mean age of patients in group A and group B was 31.38±9.03 years and 30.10±9.35 years respectively. Data of this study in terms of mean age is widely supported by Zafar KJ where he reported mean age with 32.4. Gokkulakrishnan et al [17] showed in his study mean age of 30.9. One study carried out by Al-Tairi et al [18] came with mean age with less than 25 years i.e 24.5 years.
The operating time needed in group A (Conventional 2mm miniplate) was < 30minutes in 22(46.8) cases and >30 minutes in 25(53.2%) cases, while in group B all 47(100%) cases were found with intra operative time<30 minutes. According to the studies by Zafar KJ [15], Kumar [19], Kinra [20] and El Nakeeb [16] they also reported decreased operating with 3-D plates as compared to 2 conventional miniplates for the fixation of anterior mandibular fracture.
The initial biomechanical research on 3D plates was carried out by Farmand, and he establish that the constancy of 1 mm 3-D plate was comparable to the much thicker 2-0 mm miniplates (Steinhauser plate), which is intended for a single plate fixation of mandibular fractures. The final stability also appears to be compromised in Steinhauser's plate because eof its deficient screw-bone interface [13]. In contrast our study showed no significant difference in terms of stability at 12 th week follow up period in both groups.
In current study clinical and radiological malunion was found at the 8th week follow up was 14.8 % in group A and 8.5% in group B. Studies published by Kishor K [21] and Sadhwani BS [9] showed no case with malunion in both groups at the end of follow up period.

CONCLUSION
The results of the current study showed good stability, less procedure time required, less malunion with 3-D plating system. It can be concluded by the findings that 3-D plating system has advantages over conventional 2mm miniplates.

CONSENT AND ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s). Patients who fulfilled the inclusion criteria and gave written informed consent for the study were enlisted for this study.