Current Evidence for the Management of Edentulous Atrophic Mandible Fractures: A PRISMA-SWiM Guided Review

Abstract

Study Design: PRISMA-SWiM guided systematic review. Objective: 1. Provide consistent evidence regarding the management of atrophic mandible fractures; 2. To search, evaluate and validate existing guidelines if any for the management; 3. Provide evidence regarding specific management of condylar fractures in the atrophic mandible; 4. To address the clinical applicability of bone grafts. Methods: A systematic review was conducted using the PRISMA-SWiM protocol. PROSPERO ID: CRD42021235111. Studies with adequate data on outcome, treatment methods were selected. Isolated case reports, case series, and nonhuman studies were excluded. Quality assessment was done using Newcastle -Ottawa scale. The level of evidence was assessed using Oxford Level of Evidence. Results: Mandibular body was the most common type of fracture. Self falls and RTA were the most common etiologies. Condylar fracture was most commonly managed conservatively with ORIF employed in few studies. For the mandible compression and non-compression osteosynthesis were used. Bone grafts were used in cases with segmental defects or cases requiring augmentation. Conclusions: There is lack of proper evidence to definitely conclude any single treatment modality. However, the consensus is towards ORIF. Reconstruction plates are preferred by many authors. However, unilateral fractures may be managed by miniplates. Bilateral fractures require more rigid fixations. Open reduction and internal fixation of condylar fracture is indicated in cases with displacement or low-level fractures.

Introduction

Background

Fractures of the edentulous mandible have an overall incidence of 1%–5% amongst all mandible fractures. [1] The consequence of tooth loss leads to a progressive atrophy of the jaws increasing the susceptibility for fractures. [1,2,3] A number of challenges are frequently encountered while managing these subset of fractures: poor bone quality, decreased blood supply, and osteogenesis and complica-tions which can range up to 20% in some cases particularly delayed unions. [1]

Contemporary treatments either involved conservative management or a “skilful neglect.” The closed reduction techniques involve dentures with circummandibular wiring, indirect skeletal fixations, gunning splints, MMF (maxilla mandibular fixation) with arch bars embedded in dentures, external pin fixation etc. [4] Welsh and Welsh in 1976 gave a preliminary idea of management of edentulous maxilla and mandible fractures. Unlike dentate mandible fractures, an edentulous mandible fracture is greatly influenced by muscle traction. Thus, all fractures of the mandible body and symphysis can be considered as unfavorable. Open reduction and wire fixation followed by stabilization of denture with circummandibular wiring was the mainstay of treatment. [5]

Management of mandible fracture in the elderly patients is complicated by a number of factors: systemic health, degree of atrophy, degree of displacement, and postoperative complications. [6,7] Towards the beginning of 90s, open reduction and internal fixation with bone plates for the edentulous mandible fracture became more popular. However, the incidence of fibrous union was still high (12.5%). [6] Krebs in 1988 advocated the use of dynamic compression plates for the management of these fractures. There was no incidence of delayed union. Two patients had minor infections. [8] A quite high success rate with compression plating was achieved by Levine 1982, Bruce 1993, and Luhr 1996. [9,10,11] On the other hand, Thaller [12] 1993 recommended the use of smaller dimension plates. [12] Gerbino et al. [13] 2018 in their retrospective series advocated that load bearing fixation is the gold standard for treating these fractures. [13] However, a number of authors have reported good success with the use of smaller dimension plates. [14,15,16,17,18,19,20] Batbayar et al. [21] used both load bearing and load sharing fixation according to the degree of atrophy, continuity defects, displacement, and associated fractures. [21]

The most important decision to choose a load bearing or load sharing fixation is the degree of atrophy and other factors as addressed by Batbayar et al.

The classification of atrophic mandibular fractures was given by Luhr in 1996. They used reconstruction plates for most of the cases; extremely atrophic cases were managed with miniplates and lag screw was used only in oblique fractures. They stated that placement of miniplates along the lower border may result in “out of plane bending” because of the suprahyoid pull of the musculature and hence it should be avoided. [11] The failure of miniplates in atrophic mandibles may be due to “wishboning” leading to hardware fatigue and failure. [22] Kim et al. 2018 [18] also recommended load bearing plates for atrophic mandible; however, they recommended that the degree of atrophy should not be the only criterion for plate selection rather the general health condition of the patient should also be taken into consideration. The 2013 updated systematic review of Nasser et al. [7,23] could not recommend a single best modality of treatment for management of atrophic mandible fractures. They concluded that treatment should be based on clinician’s prior experience and case perspectives.

Objectives:

• Provide consistent evidence regarding the management of atrophic mandible fractures.
• To search, evaluate, and validate existing guidelines if any for the management.
• Provide evidence regarding specific management of condylar fractures in the atrophic mandible.
• To address the clinical applicability of bone grafts

Methods

Protocol and Registration

The current review is in accordance with the SWiM extension of PRISMA. [24] The study has been registered with PROSPERO (ID: CRD42021235111).

Eligibility Criteria. The PICO questionnaire has been used to assess the eligibility of the studies. [25]

Population: patients with atrophic edentulous mandible fracture.

Intervention: rigid fixation, conservative management, miniplates, reconstruction plates, lag screws, maxillomandibular fixation, open reduction, closed reduction, internal fixation, external fixation, screws, compression plating, non-compression plating, bone grafting, and splints.

Comparison: Edentulous vs non edentulous fractures.

Outcome: infection, delayed healing, plate fracture, and neurosensory disturbances.

Study Design: Clinical trials, prospective, and retrospective studies, case series >10 cases.

Focus questions: “What is the ideal modality of treatment for the edentulous fractured mandible?” “Do they require bone grafting?”

“What are the complications and what has been the trend from past to present?”

Data sources: Electronic (MEDLINE (PubMed), https:// www.ncbi.nlm.nih.gov/pubmed/; EMBASE, https:// www.embase.com/; and Cochrane database, http://www. cochranelibrary.com, clinicaltrials.gov, ctri.nic.in) and manual literature searches (Hand searches were done where articles or abstracts were not available electronically).

Search terms: (“mouth, edentulous”[MeSH Terms] OR (“mouth”[All Fields] AND “edentulous”[All Fields]) OR “edentulous mouth”[All Fields] OR “edentulous”[All Fields]) AND (“atrophy”[MeSH Terms] OR “atrophy”[All Fields] OR “atrophic”[All Fields]) AND (“mandibular fractures”[MeSH Terms] OR (“mandibular”[All Fields] AND “fractures”[All Fields]) OR “mandibular fractures”[All Fields] OR (“mandible”[All Fields] AND “fracture”[All Fields]) OR “mandible fracture”[All Fields]).

Search Dates: till February 2021. Language Filter: English only.

Inclusion Criteria

• Clinical trials, interventional and observational studies on the management of atrophic mandible fractures.
• Case reports with >10 cases.
• Language Filter: English
• Studies with data on at least one of the post operative outcomes described above.

Exclusion Criteria. Review articles, case reports <10 cases, cadaveric, laboratory studies, or animal studies.

Study Selection. Two reviewers screened all identifiable titles and abstracts independently. In addition, the reference lists of the subsequently selected abstracts and the bibliographies of the systematic reviews, human randomized, and nonrandomized controlled trials and; prospective and retrospective cohort studies were searched manually. For studies appearing to meet the inclusion criteria, or for which insufficient data in the title and abstract was available, the full text was obtained. Disagreements were solved through discussion between the reviewers. The inter-rater reliability was assessed using Cohen’s Kappa; values ≤0 indicated no agreement, .01–.20 as none to slight, .21–.40 as fair, .41–.60 as moderate, .61–.80 as substantial, and .81–1.00 as perfect agreement. Finally, the full-text evaluation of the remaining publications was done using the above-listed inclusion and exclusion criteria.

Quality Assessment

Quality assessment of the selected studies was executed by Newcastle–Ottawa scale. Scale was applied for cohort studies to judge each included study on selection of studies, comparability of cohorts, and the ascertainment of either the exposure or outcome of interest. Stars were awarded such that the highest quality studies were awarded up to nine stars. The Oxford Level of Evidence was used to assess the strength of the studies. [26,27]

The Oxford 2011 Levels of Evidence

Level Category of evidence

I SR (with homogeneity) of RCT Individual RCT

II SR (with homogeneity) of cohort studies

Individual cohort study (including low-quality RCT. For example, <80% follow up)

“Outcome” research; ecological studies

III SR (with homogeneity) of case-control studies Individual case-control study

IV Case series and poor-quality cohort and case-control studies

V Expert opinion without explicit critical appraisal, or based on

Physiology, bench research or first principles

SR = systematic review, RCT = randomized controlled trials.

A meta- analysis could not be performed because of the heterogeneity of the data.

Results

Figure 1 describes the study selection process according to the Prisma Guidelines. Cohen’s Kappa coefficient was applied at each step. A total of 24 articles were included for the review.

Table 1. Full Text Articles Excluded with Reason.

tabulates the full text articles excluded from review. Three articles were not found either electronically or through hand searches and are mentioned in

Table 2. Articles Which Could not be Fetched Through Hand or Electronic Searches and Hence Excluded from Review.

. They were also excluded from this current review.

A total of 627 patients were included in the study.

Table 3. Individual Study Characteristics.

depicts the demographics and follow ups of each included study. The most common site of fracture was the mandibular body followed by the angle region. The most common cause for fracture was self falls followed by motor vehicle accidents, assaults, road traffic accidents etc.

Table 4. Study Outcomes, Quality of Studies, and Level of Evidence.

denotes the outcome of each study, study quality, and level of evidence. Most of the studies were either retrospective case series or retrospective cohort. None of the included studies are clinical trials or prospective in nature. The treatments rendered were observation, conservative treatment, extramucosal fixation, lag screws fixation, reconstruction plating, compression plating, Herbert screws, circummandibular wiring, and mini plates.

Soft tissue infection was present in a total of 21 patients. Delayed healing was present in 19 patients; pseudoarthrosis in 6, bone necrosis in 7, fibrous union in 2, osteomyelitis 2, and non-union 2 cases.

Transient IAN nerve injury was present in 66 patients and permanent in only 1 patient. Transient facial nerve injury involving the marginal mandibular branch was seen in 15 patients and permanent in 2 patients. The other infrequent complications are tabulated in Table 4.

Discussion

Key Results

The most common site of fracture was the mandibular body. Both load bearing and load sharing fixation, compression and non-compression osteosynthesis, conservative methods were used for management. Luhr and Cawood classifications were most commonly used to classify these fractures.

Limitations

• None of the studies are clinical trials and hence the level of evidence is poor to suggest any definitive treatment.
• Except one study by Kim et al., all are non-comparative studies. A true comparison of outcome could not be drawn in relation to fractures of the dentate mandible.
• There is poor evidence regarding the management of condylar fractures.
• None of the studies have actually measured neurosensory outcomes. The measurements are subjective and may have bias.
• There is a lack of proper guideline or protocol to manage these fractures as being considered as a limitation in a number of included studies.
• Very limited data on the influence of age, sex, and systemic illness on outcomes.
• Inadequate data on management of post operative complications and its relationship with study variables.

Interpretation

Age/Sex and Co Morbidities. In the study by Bruce et al., the mean age of patients who had delayed healing was 57.4 years not significantly different from the entire sample (54 years). Older patients have thinner mandibles making them more susceptible to displacement and requiring longer periods of immobilization.

Fractures in the atrophic mandible occur in patients who might suffer from a variety of systemic conditions (osteoporosis, osteoarthritis, cardiac problems etc.) which affects the anesthetic and post operative management of the patients. The aging process also has a direct relationship with the duration of MMF required for union of these fractures. Edentulous mandible might require >4 weeks of fixation to achieve clinical union [Bruce et al.]. In their study, Eyrich et al. had three patients with fracture secondary to systemic illness (osteoporosis, renal failure, and malnutrition). In the study by Müller et al., patients with systemic diseases needed early mobilization and rehabilitation for better dietary and functional needs. Franciosi et al. stated that as in most of the patients the biological and biomechanical condition could not be modified it is the type of osteosynthesis which would decide the prognosis of the fracture. They also recommended non-surgical management in patients with poor health conditions. However, the extent of the conditions was not described and also in their study it was only the condyle fractures that were conservatively treated. Hidalgo et al. stated that aged patients may be less ideal candidates for general anesthesia. However, closed reduction did not provide the necessary stability required for healing. Maxilla mandibular fixation may be associated with poor outcomes like respiratory problems and TMJ dysfunction. Gerbino et al. had three patients included in their study who already had delayed healing and infection requiring revision surgery. They also recommended early intervention with ORIF as better compared to closed techniques which might further worsen the general condition of the patient. Open reduction and internal fixation in atrophic mandibular fractures is technically more conservative in terms of quality of life. Observation and conservative therapy is only recommended for patients who cannot withstand general anesthesia.

Brucoli et al. [1] their study did not show in significant difference in terms of timing of intervention, treatment, co morbidities, and concomitant injuries. Brucoli et al. [19,20] did not find any significant relationship of co morbidities or timing of intervention on outcome.

Timing of Intervention. Brucoli et al. [1] reported on patients who presented within 24 hours to >72 hours. However, no statistical difference was seen. Early vs delayed treatment is a debatable issue. Nevertheless, general condition of the patient and financial factors are important considerations. In the study by Bruce et al., the mean timing for intervention from fracture was 5 days with 53% being treated within 3 days of injury. The mean delay in intervention in patients with complications was 6.7 days (approximately 2 days more than the average sample).

Iatrou et al., most patients were treated within 2–7 days of injury with a mean of 6 days. Delay in treatment up to 14 days occurred in patients with systemic illness. Clayman et al. recorded a maximum delay of 2 weeks with maximum patients being treated within 24–36 hours. They discussed even after delay to 72 days the infection rates were 4%–7%.

However, there is a lack of strong data supporting any correlation between delayed treatment and successful treatment and infections. The average time between injury and treatment as discussed by them was 6.2 weeks with most authors. [16] The mean time period from injury to treatment was 10.7 days in the study by Mugino et al. [29] In general, most of the studies have concluded on early intervention for better rehabilitation of the patients. Due to the heterogeneous data, a definitive time interval could not be predicted.

Closed vs Open Reduction. Some of the earlier studies; Bruce et al., Thaller et al., Eyrich et al., Mugino et al., Wittwer et al., and Brucoli et al. have used some form of closed reduction for the management of these fractures. Gunning splints or dentures were the commonly used materials for closed reduction. In the study by Bruce et al. more than 12.5% of fractures and 15% of patients ended up with fibrous union. Fibrous union was present in total of 26% of patients treated with closed reduction. Closed reduction if applied is most suitable for fractures anterior to the molar area, posterior to the molar area any form of denture, or splint used would fail to stabilize the distal fragment. [9] Current recommendations are towards ORIF in case of these fractures: perfect reduction, direct visualization, fragment stability, and early rehabilitation are the advantages of ORIF. It is now accepted that bone stability is far more important than minimal disruption of blood flow as studies have shown good healing even in poorly vascularized bones. [31]

Compression, Non Compression Osteosynthesis, Load Bearing, and Load Sharing Fixation. The initial studies of Levine, Krebs, Bruce, and Luhr used compression osteosynthesis for treating these fractures. Levine et al. in their study pointed out that although compression osteosynthesis had affirmative advantages but certain limitations curb their utilization in atrophic fractures; they cannot be used in comminuted fractures, in condylar fractures and atrophy with less than 10 mm of available bone height. Luhr et al. used miniplate osteosynthesis for class III atrophy. Mugino et al. successfully used miniplates and microplates for the management of these fractures. They stated that owing to the atrophy it is difficult to adapt a reconstruction plate. The edentulous mandible is subjected to a variety of displacing forces at the body region. Hence, two miniplates might be required to counteract these forces particularly in class II cases. When two plates are used, one plate might be placed under the inferior alveolar nerve or along the superior border of the mandible and the other might be placed along the inferior border. If inadequate space exists, then a microplate may be used instead. Ellis and Price on the other hand used only reconstruction plates for management. They stated that the miniplates do not offer adequate resistance against the tensile forces being generated on the edentulous mandible body despite the bite forces being low compared to dentate mandibles, the possibility of miniplate fracture exists. Because of the concomitant superior and inferior direction of muscular pull which causes cyclic fatigue of the miniplates, a single plate may not be able to withstand the forces and readily gets fractured. When the bone height was adequate for the placement of two miniplates the authors recommend using a larger reconstruction plate instead. Müller et al. stated that in atrophic fractures a load bearing osteosynthesis is required as rigidity seemed to be the most important factor in fracture healing. Melo et al. in their study did not encounter fracture of plates as most of the patients underwent two miniplate fixations. Clayman et al. used single miniplate along the inferior border based on the biomechanical principles of Madsen and Haug. [36] Kim et al. in their study managed atrophic fractures with both reconstruction and miniplates. No significant difference in post-operative occlusion and complications were noted. They recommended selecting plates according to the general health status of the patients, extent of soft tissue damage, and patient expectations. Gerbino et al. also preferred load bearing fixation. They also preferred standard subperiosteal plate placement rather than supraperiosteal placement as the later would have compromised blood flow to the periosteum. Load bearing locking reconstruction plates could be placed both on the lateral aspect and inferior border of the mandible to provide adequate stability against the torsional and tensile forces. In general, smaller the mandible larger should be the thickness of the plate. Batbayar et al. recommended open reduction with bone graft + load bearing fixation for bone height <10 mm and either load bearing or load sharing fixation without bone graft for height >10 mm. Brucoli et al. [19] in their study treated most Luhr class I and II with reconstruction plates and Luhr class III with two 2.0 miniplates. Single miniplates were also used in 25–35% of patients in each category of Luhr classification. However, the study focused on unilateral fractures only. Bilateral fractures demand more rigid fixation.

Lag Screws. Luhr et al. 1996, [11] Eyrich et al. 1997, [28] Ellis and Price 2008, [4] and Kim et al. 2018 [18] have used lag screw osteosynthesis to treat some of the fractures. None of these studies described the outcomes specific with lag screws. In general, they considered oblique fractures with good bone on either side as the indication. Hence, strong evidence is lacking to conclude in this aspect. However, no complications in either of the studies using lag screws have been documented. Ellis and Price have used lag screws only as a mean for temporary anchorage. Internal fixation in their study was done with plates.

Condyle Fracture in the Atrophic Mandible. Bruce et al., [10] Thaller, [12] Luhr et al., [11] Eyrich et al., [28] Mugino et al., [29] Melo et al., [14] Novelli et al., [15] Clayman et al., [16] Franciosi et al., [17] Kim et al., [18] Batbayar et al., [21] Brucoli et al., [20] and Brucoli et al. [1] reported on the management of condyle fracture in the edentulous mandible. However, only few of them actually discussed the outcomes separately.

None of the condylar fractures in the study by Bruce et al. were treated by open reduction. The absence of teeth negated exact anatomic reduction as irregularities could be overcome with denture fabrication. Intermaxillary fixation was also applied in only one third of patients. They believed that any loss of posterior vertical height/ramus height could be accommodated with prosthesis fabrication. Luhr et al. also used conservative means for treating the condylar fracture. They used molar acrylic stops over the denture and applied light frontal elastics for a period of 2–4 weeks. Franciosi et al. also treated their condylar fractures conservatively. However, no discussion was made on the outcome. The study of Kim et al. although mentioning of operating the condyle did not tabulate any outcome or specific hardware used to manage the condyle fractures. Batbayar et al. in their protocol study managed condyle fractures with both closed techniques and open reduction. All the high condylar fractures were managed with closed reduction. All of the low condylar fractures were managed with open reduction and load sharing fixation except one which underwent closed reduction. Brucoli and Buffano [1] in their retrospective survey found that condylar fractures were more common in Luhr I and II. They concluded that the fracture biomechanics of Luhr I and II atrophic mandibles were similar to dentate mandible and hence the commonness of condylar fractures was seen. In Luhr III, the inherent thinness of body and parasymphyseal regions predisposed them to fracture. Another study by the same authors [20] reported exclusively on the management of condylar fractures. Of the total 52 patients, 11 underwent open reduction, 4 underwent closed reduction, and observation was performed on 37 patients. Only two patients in the observation subgroup had complications, TMJ pain, and limited mouth opening. In this study, the incidence of condyle fracture was not associated with Luhr classification. Head fractures were mostly managed conservatively. For low level condylar fractures, ORIF was indicated if the fracture was displaced, dislocated, or there was shortening in the vertical height. They also stated that the treatment was decided in certain cases if the patients had dentures that could be used for closed reduction. Although the current study favored open reduction based on predetermined parameters, it is difficult to conclude whether ORIF can be considered as definitive management since the study by Bruce et al. aptly concluded the malalignment in bone did not affect functioning and it could be overcome with prosthesis fabrication. Another important consideration is the general health of the patient as many of the studies reported on co morbidities associated with mandible fractures. These factors preclude the clinician from treating an edentulous mandibular condyle with open reduction.

Bone Grafting. Some of the earlier attempts of bone grafting in edentulous fracture was made by onlay rib grafts which would act as a splint, vertically augment the mandible, and provide increased contact area for healing. [9]

Ellis and Price used bone grafts mostly from the anterior ilium along with tibial and posterior iliac grafts in few cases. Eyrich et al. used split rib bone grafts for bridging osteosynthesis in class VI Cawood and Howell atrophic fractures. Few patients with class VI atrophy also received augmentation with iliac grafts, microvascular fibula, and rib grafts.

Immobilization of grafts is necessary which increases healing rate and residual bone volume. Proper fixation of grafts decreases strain and resorption and thus increase bone volume. [31] Bone grafting is required in patients with continuity defects, patients requiring dental implants, or in cases with severe atrophy (height <1 cm). [21,35] In a nutshell, the indications for bone grafting are:

• Bone loss/bone defects (continuity defects) [Mugino et al., Melo et al., Franciosi et al., Hidalgo et al., and Gerbino et al.).
• Comminuted and complicated fractures [Müller et al., Eyrich et al., Melo et al., and Franciosi et al.].
• Severe atrophy (Luhr III, Cawood and Howell class VI) [Eyrich et al., Mugino et al., Luhr et al., Wittwer et al., and Müller et al.]
• Partial bony defect resulting from removal of impacted teeth [Luhr et al.]
• Treatment of non-consolidated fractures [Melo et al.].
• Pathological Fractures [Eyrich et al.]
• Dental Implant based rehabilitation [Melo et al., Franciosi et al., and Hidalgo et al.]

Gerbino et al. stated that for implants, the mandibular body (most common site for fracture) is not suitable as the bone in atrophic mandible is already pencil thin and with the current advent of all on 4 techniques implants could be successfully placed in the parasymphyseal and symphysis area with better bone stock.

Complications. Management of edentulous atrophic mandible fractures suffers complications due to either biologic or biomechanical causes. The biologic causes include patients’ overall health and the biomechanical causes include lack of buttressing effect of the bone and stability associated with specific form of fixation. [36] Some of the earlier studies arrayed a complication rate up to 20% in case of edentulous mandible fracture management. [8,9] These fractures might suffer from a high incidence of delayed union owing to the decreased central blood supply of the mandible. Levine and Krebs in their study with DCP and EDCP plates showed negligible complications in terms of delayed union.

Compression plating leads to less severance of the periosteum and provides immobilization to a fracture site which leads to better healing and fewer chances of delayed union.[8,9,11]

Some of the newer studies reported very fewer or in some cases no incidence of delayed healing, preserving the periosteal blood supply seems to be more important than rigid fixation. [19]

Nerve paresthesia is usually transient following fracture management. Clayman et al. in their study reported a permanent nerve paresthesia involving the mental nerve. Permanent injury to marginal mandibular nerve occurred in two patients of Gerbino et al.

Other complications like osteomyleitis, pseudoarthrosis, fistula etc. are rare with the recent studies. Osteomyelitis was treated with sequestrectomy and bone grafting with compression plating in the study by Luhr et al. Reosteosynthesis due to infection was done in a single patient of Müller et al.

With modern day plating systems, the overall infection rates are in the range of 4%–7%. [16]

Supra vs Subperiosteal Plating. Another controversy is whether the plate should be placed subperisoteal or supraperiosteal. The factor in favor of supraperisoteal placement was the disruption of subperisoteal plexus which is believed to be the major source of blood supply to the edentulous mandible. Authors who favored subperisoteal placement stated that the disruption of blood supply would be similar even if the plate was placed supraperiosteal. Further studies have shown that even with a properly contoured plate the implant to tissue contact is less than 30% and also sub-perisoteal dissection leads to greater stripping and interference to blood supply compared to supraperisoteal placement. [11] Benech et al. [34] in their study used extramucosal plating for bilateral fractures of the atrophic mandible. Of the 13 cases, 1 patient developed pseudoarthosis. The authors believed that a combination of adequate stability and perseverance of blood supply to the bone and mucosa are potential advantages while risk for infections and malalignments are the disadvantages.

The biomechanical study by Madsen and Haug showed that fixation of reconstruction plate at either lateral border or inferior border resulted in insignificant difference in terms of displacement or stiffness.

Generalizability

Answer to our initial focus questions:

• “What is the ideal modality of treatment for the edentulous fractured mandible?”
• No treatment is absolute as conclusive data from clinical trials are lacking. In general, the trend has shifted towards ORIF with load bearing as well as load sharing fixation. With miniplates at least two miniplates are required. Greater the atrophy, larger should be the plate. Most of the authors, however, preferred reconstruction plates. In case of condylar fractures, high condylar fractures and undisplaced fractures can be effectively managed conservatively. Displaced fractures and low-end fractures should be managed with ORIF.
• “Do they require bone grafting?”
• Bone grafting is required in cases with severe atrophy, where the residual height is less than 1 cm. It is also required in cases with continuity defects and for vertical augmentation foe implant-based rehabilitation
• “What are the complications and what has been the trend from past to present?”

In the past, the major complications were infections, nerve injuries, and delayed healing (in some cases upto 20%). In the present scenario, major complications are rare. Most of the studies have very rare reports on delayed healing. Nerve injuries continue to be one of the common complications; particularly the inferior alveolar nerve, mental, and marginal mandibular nerve

Conclusion and Clinical Relevance

There are no separate universal guidelines for the management of condylar fractures. In general, the treatment does not differ significantly from dentate patients. The general consensus for management of mandibular fractures is ORIF with load bearing fixation. Low condylar fractures ORIF can be done. Nevertheless, unilateral fractures can be managed adequately with load sharing fixation. Where miniplates are used, it is preferred to use two miniplates, one along the lateral border and one along the inferior border. In cases of angle fracture, a single miniplate may still be used. However, neither of the recommendations is absolute and all the conclusions are supported with moderate to poor quality of evidence.