What is the recommended treatment for a simple angle of mandible fracture using an external approach, according to the AO (Arbeitsgemeinschaft für Osteosynthesefragen) guideline?

Management of Simple Mandibular Angle Fractures Using External Approach

For simple, non-comminuted mandibular angle fractures, the current AO-influenced standard is a single monocortical miniplate placed on the superior border (Champy technique), which demonstrates lower complication rates than traditional dual-plate or compression techniques. 1, 2

Preferred Fixation Technique

A single miniplate on the superior border using monocortical screws in a non-compression technique is the optimal approach, as this method is favored by 51% of high-volume AO faculty (treating >10 fractures annually) and demonstrates significantly lower rates of infection, reoperation, and hardware removal compared to alternative methods. 1, 2

Technical Specifications

• Single miniplate placement: Superior border of mandible (external oblique ridge) 1, 3
• Screw type: Monocortical, non-compression technique 2, 3
• Plate positioning: Non-compression (neutral screw placement) rather than eccentric placement 1, 2

The meta-analysis evidence is compelling: single-plate fixation shows significantly lower complication rates across all measured outcomes compared to dual-plate systems. 2

Alternative Techniques (When Champy Approach Insufficient)

If a single superior miniplate provides inadequate stability, the secondary option is:

• Tension band plate on superior border PLUS non-locking bicortical screw plate on inferior border 1
• This dual-plate approach is used by 13% of AO faculty as primary technique, though 73% employ it selectively in specific circumstances 1
• When using inferior plates, 51% of surgeons favor neutral screw placement over eccentric (compression) placement 1

Maxillomandibular Fixation (MMF) Considerations

Intraoperative MMF is not mandatory for all simple angle fractures. 1

• 16% of surgeons often perform fixation without MMF
• 23% occasionally omit MMF
• Only 41% never omit MMF 1
• International faculty are significantly less likely to use intraoperative MMF compared to North American faculty (81% vs 43%, P<0.01) 1

Critical Evidence-Based Advantages of Single Miniplate Technique

The superiority of single monocortical miniplate fixation is supported by meta-analysis demonstrating:

• Lower infection rates compared to compression techniques, bicortical screws, and dual-plate systems 2
• Reduced reoperation rates compared to compression and dual-plate approaches 2
• Decreased hardware removal compared to compression and dual-plate methods 2
• Shorter operative time compared to dual-plate techniques 3
• Better stability outcomes compared to dual-plate systems in retrospective analysis 3

Common Pitfalls to Avoid

• Avoid compression plating: Compression techniques show significantly higher infection and malunion rates compared to non-compression methods 2
• Avoid routine dual-plate fixation: Two-plate systems demonstrate higher infection, reoperation, and hardware removal rates 2
• Avoid bicortical screws when monocortical sufficient: Bicortical screws show higher infection rates 2
• Do not miss the second fracture: 67% of mandibular fractures occur in pairs due to U-shaped configuration; systematically examine entire mandible 4
• Screen for associated injuries: 39% have intracranial injuries and 11% have cervical spine injuries 4

Special Consideration for Infected Fractures

Even in the presence of infection, rigid internal fixation remains biologically sound and effective, with successful osseous union achieved without requiring plate removal in properly managed cases. 5