Abstract
Background
Titanium mesh provides three-dimensional stability, it is easier and quick in placement, highly malleable and adaptable hence, proved to be worth in restoring the function and form in cases of comminuted maxillofacial fractures.
Materials and Methods
A total of 12 patients were included in this retrospective study at Department of Oral and maxillofacial surgery, Sri Rajiv Gandhi College of Dental Science and Hospital, from December 2015 to June 2020. Out of 12 patients, 7 reported with frontal bone fracture and 5 reported with mandibular fracture. Patients were followed up for upto 18 months to evaluate efficacy of titanium mesh on postoperative long-term healing, aesthetic outcomes and return to normal function were evaluated.
Results
The results have shown that titanium mesh has low complication rates and the ability to maintain occlusion and chewing postoperatively. Union occurred without complication in 90% of fractures, and patients treated for frontal bone fracture had excellent cosmetic results.
Conclusion
The semi rigid nature of the titanium mesh fixation allows micro movement at the healing bone ends, reduces stress shielding effect which may improve functional bone healing. Bony continuity of the mandible can be restored providing three-dimensional morphology and stability. The versatile placement of screws is the principal advantage.
Keywords: Titanium mesh, Comminuted fracture, Mandible fracture, Frontal bone, Fracture, Maxillofacial
Introduction
The management of comminuted maxillofacial fractures remains a challenge for surgeons due to its high infection rate, difficulties in restoring the contour of fractured sites and severe bone displacement and bone loss [1]. Treatment methods of facial fractures have evolved greatly over the years, from supportive bandages, splints, circummandibular wiring, external pin fixation, semi-rigid fixation with transosseous wiring to open reduction and internal stable fixation (ORIF) using miniplates, reconstruction plates or screws [2–7]. The need for the open reduction of severely comminuted mandibular fractures was recognized by Kazanjian during his management of World War I injuries (Kazanjian 1942) [8]. When compared with miniplates, it provides better three-dimensional morphology and stability, low infection rate, is highly adaptable, and prevents the development of fracture line infection and non-union [9–11]. The semi-rigid nature of the mesh fixation allows micro-movement at the healing bone ends which may improve functional bone healing, and it is further postulated that this may prevent the stress-shielding which occurs under rigid plates in mandibular continuity defects [12]. The stability that can be accomplished with titanium mesh apparently results in revascularization of the comminuted segments and their long-term retention. The objective of this study was to evaluate the efficacy of titanium mesh on post-operative long-term healing and return to normal function based on its intraoperative use and also post-operative assessment.
Materials and Methods
A total of 12 patients who had been diagnosed with traumatically comminuted fractures and treated with open reduction and internal stable fixation (ORIF) with titanium mesh were included in this study at Department of Oral and maxillofacial surgery, Sri Rajiv Gandhi College of Dental Science and Hospital, from December 2015 to June 2020. Preoperatively, complete case records of these enrolled patients were retrieved and reviewed to obtain information regarding patient demographics and clinical features, the aetiology of injury, associated medical comorbidities, fracture site and fracture type. The ethical clearance for the study was given by the institutional review board, and informed consent was taken by all the patients. Out of 12 patients included in the study, 10 were males and 2 females (Table 1 depicts patient’s details). The mean age of 12 patients was 40.3 years (range 20–64 years). The most common mode of facial injury was RTA (Road Traffic Accidents). Clinical information including patient’s gender, age, aetiology of injury, fracture type, fracture site, and associated medical comorbidities was noted. Thorough radiological evaluation was done including CT scan (computed tomography) and 3D (three-dimensional) facial bones reconstruction images. Out of 12 patients, three patients had isolated mandibular fractures, two patients had isolated frontal bone fracture, and seven patients presented with combined mandibular, maxillary, frontal and orbital bone fractures. And the objective of this study was to evaluate long-term healing, aesthetic outcomes and return to function during follow-up which was planned routinely for all the patients with intervals of 3, 6, 12 and 18 months post-operatively.
Table 1.
Patient’s details
| Case number | Gender | Age | Etiology | Fracture site |
|---|---|---|---|---|
| 1 | Male | 38 | RTA | Frontal bone |
| 2 | Male | 40 | RTA | Frontal bone and right body of mandible |
| 3 | Male | 43 | RTA | Frontal bone |
| 4 | Male | 45 | RTA | Frontal bone and bilateral ZMC |
| 5 | Male | 62 | RTA | Frontal bone and left infraorbital |
| 6 | Male | 64 | Assault | Frontal bone and bilateral infraorbital |
| 7 | Male | 30 | Assault | Bilateral parasymphysis of mandible |
| 8 | Male | 40 | High fall injury | Frontal bone and right ZMC |
| 9 | Male | 32 | High fall injury | Bilateral angle of mandible and bilateral ZMC |
| 10 | Male | 20 | Sports related | Right body of mandible |
| 11 | Female | 51 | RTA | Right parasymphysis of mandible |
| 12 | Female | 24 | Assault | Left body of mandible and right condyle |
RTA Road traffic accident, ZMC Zygomatico maxillary complex
Cosmesis
It was evaluated based on post-operative radiographs and feedback from the patient and/or the patient’s family based on a 4-point scale (0—no deformity compared with preoperative state, 1—mild deformity, 2—moderate deformity, and 3—severe deformity) [13, 14].
Long-Term Healing
Long term healing was evaluated by observing the presence of any local infection, fistulas, wound dehiscence, sinusitis and also paraesthesia which was evaluated by examining the function of trigeminal nerve using 3-point scale (2—No change compared with preoperative sensation, 1—altered or decreased sensation, 0—loss of sensation) [13, 14].
Occlusion
Except the two patients who had isolated frontal bone fracture, occlusion was only evaluated by the other 10 patients as well as the surgeon at the 3rd month post-operatively by giving scores as follows:
Patient’s perception (Good 2: occlusion same as prior to surgery on both sides, Fair 1: occlusion same as prior to surgery on one side, Poor 0: not the same as prior to surgery).
Surgeon’s perception (Excellent 3: satisfactory bilaterally and the same as before injury, Good 2: satisfactory bilaterally but different from before injury, Fair 1: only satisfactory unilaterally and the same as before injury and Poor 0: unsatisfactory bilaterally and different from before injury).
Mastication
Except the two patients who had isolated frontal bone fracture, mastication was evaluated by the other 10 patients at the 3rd month post-operatively by giving scores as follows: 3 (Excellent—normal bilaterally and on normal diet), 2 (Good—normal unilaterally and on normal diet, 1 (Fair—on soft diet), and 0 (Poor—unable to chew bilaterally).
Surgical Technique
The surgery was performed under general anaesthesia. For the frontal bone fracture, bicoronal incision was used in 5 out of 7 patients and hemicoronal incision in the other 2 patients. For mandible fracture, the fracture site was exposed with intraoral vestibular degloving incision for body and parasymphysis fracture, extraoral submandibular incision was used for angle fracture as it provides versatile access making it easy to manipulate and stabilize titanium mesh in the fracture site, and preauricular approach was used for condylar fracture. After the fractured and the displaced fragments were reduced, the titanium mesh of desired size was cut using a mesh cutter intraoperatively. According to the morphology, extent of fracture and comminution, the mesh was reshaped and adapted and the reduced bone fragments were fixed using titanium screws. And the other fracture sites were reduced and fixed using miniplates and screws as per the fracture site requirement. Surgical site was irrigated with saline and metronidazole wash, and layered closure was completed using 3-0 Vicryl and 4-0 Ethilon suture (Figs. 1a–e, 2a–c).
Fig. 1.
Case of comminuted mandibular fracture. a Pre-operative 3DCT showing comminuted mandibular fracture. b Exposure of fracture site. c: Reduction of fracture site. d Malleability of titanium mesh. e Titanium mesh secured. f Post-operative 3DCT
Fig. 2.
Case of comminuted frontal bone fracture. a Pre-operative 3DCT showing frontal bone fracture. b Bicoronal incision. c Titanium mesh secured. d Post-operative PNS view
Results
The age of the patients ranged from 20 to 64 years with the maximum incidence of fractures in 28–40 years age group. The male/female ratio was 10:2. The most common aetiology was RTA (82%) followed by assault, sports related injury and occupational injury. A total of 23 fracture sites were present in 12 patients. Three patients (5 fracture sites, 23%) had isolated mandibular fractures. Two patients (2 fracture sites, 9%) had isolated frontal bone fracture. Seven patients (16 fracture sites, 68%) presented with combined mandibular, maxillary, frontal and orbital bone fractures (Fig. 3). Intraoperatively in none of the cases we encountered any intraoperative mesh breakage during manipulation. Post-operatively 3DCT and PNS (Para-Nasal Sinus) view revealed favourable morphology of fractured site and no sign of resorption (Figs. 1f, 2d).
Fig. 3.
Fracture site distribution
Cosmesis
A grade of 0 (no deformity compared with preoperative state) was given for 11 out of 12 patients (91.6%) and grade 1 (mild deformity) for one patient (8.3%) with frontal bone and bilateral ZMC (Zygomatico Maxillary Complex) fracture (Table 2). Post-operative CT scan and PNS view revealed adequate reduction.
Table 2.
Scoring given for each criteria of evaluation
| Case number | Fracture site | Cosmesis | Occlusion | Mastication | Paresthesia | |
|---|---|---|---|---|---|---|
| By patient | By surgeon | |||||
| 1 | Frontal bone | 0 | – | – | – | 2 |
| 2 | Frontal bone and right body of mandible | 0 | 2 | 3 | 3 | 2 |
| 3 | Frontal bone | 0 | – | – | – | 2 |
| 4 | Frontal bone and bilateral ZMC | 1 | 2 | 3 | 3 | 1 |
| 5 | Frontal bone and left infraorbital | 0 | 2 | 3 | 3 | 2 |
| 6 | Frontal bone and bilateral infraorbital | 0 | 2 | 3 | 3 | 1 |
| 7 | Bilateral parasymphysis | 0 | 2 | 2 | 2 | 2 |
| 8 | Frontal bone and right ZMC | 0 | 2 | 3 | 3 | 2 |
| 9 | Bilateral angle of mandible and bilateral ZMC | 0 | 1 | 2 | 1 | 2 |
| 10 | Right body of mandible | 0 | 2 | 3 | 3 | 2 |
| 11 | Right parasymphysis | 0 | 2 | 3 | 3 | 2 |
| 12 | Left body of mandible and right condyle | 0 | 1 | 1 | 2 | 2 |
Cosmesis: 0—no deformity compared with preoperative state, 1—mild deformity, 2—moderate deformity, 3—severe deformity
Occlusion: Patient’s score—Good (2): occlusion same as prior to surgery on both sides, Fair (1): occlusion same as prior to surgery on one side, and Poor (0): not the same as prior to surgery
Surgeon’s score—Excellent (3): satisfactory bilaterally and the same as before injury, Good (2): satisfactory bilaterally but different from before injury, Fair (1): only satisfactory unilaterally and the same as before injury and Poor (0): unsatisfactory bilaterally and different from before injury
Mastication: Excellent (3): normal chewing bilaterally and on normal diet, Good (2): normal chewing unilaterally and on normal diet, Fair (1): on soft diet, and Poor (0): unable to chew bilaterally
Paraesthesia: 2—No change compared with preoperative sensation, 1—altered or decreased sensation, and 0—loss of sensation
Long-Term Healing
Two surgical sites developed post-operative hematoma which were managed by local drainage, and one patient with bilateral parasymphysis fracture developed wound infection which was noticed during follow-up period at 6th week and was resolved with local debridement and by administering course of antibiotics over a period of 2 weeks. On evaluation of paraesthesia, 2 out of 12 patients (24%) had altered or decreased sensation on examination of trigeminal nerve out of which one underwent surgery for frontal bone and bilateral ZMC and another patient who underwent surgery for frontal bone and bilateral infraorbital bone fracture (Table 2) around 2nd week of follow-up. This temporary paraesthesia completely got resolved within 6 months of post-operative period.
Occlusion
Patient’s Perception
A score of 2 (Good: occlusion same as prior to surgery on both sides) was reported by 8 out of 10 patients (80%). And score of 1 (Fair: occlusion same as prior to surgery on one side) was reported by the other 2 patients (20%) out of which one underwent surgery on bilateral angle of mandible and bilateral ZMC, another patient who underwent surgery on left body and right condylar fracture (Table 2).
Surgeon’s Perception
A score of 3 (Excellent: satisfactory bilaterally and the same as before injury) was given for 7 out of 10 patients (70%). A score of 2 (Good: satisfactory bilaterally but different from before injury) was given for two patients (20%) one who underwent surgery for bilateral parasymphysis, another for bilateral angle and bilateral ZMC. And a score of 1 (Fair: only satisfactory unilaterally and the same as before injury) (10%) was given for one patient with left body and right condyle fracture (Table 2).
Mastication
Score of 3 (Excellent: normal chewing bilaterally and on normal diet) was reported by 7 out of 10 patients (70%). And score of 2 (Good: normal chewing unilaterally and on normal diet) was reported by two patients (20%) out of which one underwent surgery on bilateral parasymphysis and another patient who underwent surgery on left body and right condylar fracture. And a score of 1 (Fair: on soft diet) (10%) was reported by patient who underwent surgery on bilateral angle of mandible and bilateral ZMC (Table 2).
Discussion
Comminuted fractures of the mandible have long been managed successfully with closed techniques relying on MMF and external devices in the past [15]. Combination of favourable characteristics of titanium mesh, such as three-dimensional stability, durability, malleability, and aesthetically proven morphology results, renders it suitable for the surgical treatment of complex fractures such as comminuted maxillofacial fractures and mandibular discontinuity defects. In our study, in none of the cases did we experience intraoperative breakage of the mesh during bending and adaptation. The mean age of the patients was 40.3 years (range 20–64 years), similar to the findings of Navjot Kaur et al. [2], Kostakis et al. [16]. The most common mode of facial injury was RTA (82%) Ahmed et al. [17], Chattopadhyay et al. [18] and Navjot Kaur et al. [2] also reported road traffic accidents (86.6%, 70%, and 55.2%, respectively) as the leading cause of injury. When compared with the results of follow-up studies on mandibular fractures treated with miniplates, the rate of serious complications in this series of patients was relatively low which is only 8.3% (one patient). 91.6% (12 patients) had excellent aesthetic results compared with preoperative state. In a retrospective review done by Chen et al. [14] 100% (7 patients) had no deformity for the forehead contour after surgery. Evaluation of occlusion and mastication was performed in 10 out of 12 patients as the other two had only isolated frontal bone fracture, and 80% (8 patients) of them reported good occlusal relationship and 20% (2 patients) had fair occlusal relationship. 70% (7 patients) had normal chewing bilaterally and were on normal diet. In a 7 years retrospective study done by Chakraborty et al. [19] on evaluation of efficacy of stainless steel mesh in a total of 252 patients, 82% had bilaterally satisfactory occlusion according to the surgeon at 6 months post-operatively and discomfort in chewing unilaterally or bilaterally was reported by 17% of the patients and 15.8% had local complications which required surgical removal of the implant in 24 patients. In our study on evaluation of long-term healing based on local infection, fistulas, wound dehiscence, sinusitis, and paraesthesia, 2 patients had altered or decreased sensation on examination of trigeminal nerve, 1 patient developed post-operative hematoma which were managed by local drainage and another patient developed wound infection which was managed by debridement and course of antibiotics and there was no post-operative resorption. Schug et al. [9] treated extremely atrophic mandibles, discontinuity defects and marked comminuted fractures using titanium mesh and union occurred without complication in 70% (12 patients) of fractures. Post-operatively intermaxillary fixation (IMF) with intermaxillary elastics was used for guiding the occlusion for 15 days. In the study by Dai et al. [20] intermaxillary fixation was given for only 7–10 days after surgery.
Conclusion
ORIF of comminuted fractures has the benefit of restoring continuity and returning the patient to function earlier than closed techniques. After evaluating our experience with titanium mesh for about 5 years, we can conclude that it has acceptable complication rates while providing excellent forehead contour and cosmetic results. Bony continuity of the mandible was restored providing three-dimensional morphology and stability. It has the ability to maintain satisfactory occlusion and mastication post-operatively. In our study of 12 cases, titanium mesh was well tolerated without any case of rejection. Success rate for a period up to 18 months was 100%.
Declarations
Conflict of interest
Nil.
Footnotes
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