1. J Oral Maxillofac Surg
50:434·443, 1992
Rigid Internal Fixation for the Treatment
of Infected Mandibular Fractures
MICHAEL KOURY, DDS,* AND EDWARD ELLIS III, DDS, MSt
A review of the literature is presented that shows that treatment of infected
fractures by rigid internal fixation is biologically sound. A protocol for managing
infected mandibular fractures with plate and screw fixation was developed and
used on 11 patients. All patients had osseous union of the fracture and none
required removal of the bone plate. This protocol is recommended as a viable
option in the treatment of infected mandibular fractures.
Infected mandibular fractures are common in sur- ternal fixation believe that the best manner to eliminate
gical practice because many individuals who sustain the infection is to rigidly immobilize the segments and
facial trauma fail to seek immediate treatment. On that, by doing so, bony union will occur irrespective
presentation, the patient poses a greater problem when of whether an infection is present. Thus, a dichotomy
there is a coexisting infection at the fracture site. Tra- exists in the treatment of such fractures.
ditionally, such fractures have been treated with max- When deciding whether to treat a fracture with plate
iIIomandibular (MMF) or external fixation. I However, and screw osteosynthesis, the clinician must weigh the
with the increasing interest in plate and screw fixation risk of exposing the fracture site and placing a plate
in the United States.over the past decade, new methods against the benefits ofabsolute rigidity. In the past two
oftreating infected mandibular fractures have been de- decades, research has provided much information
veloped. Rigid internal fixation offers many advantages about this dispute. To answer the questions about the
to the patient, including no MMF. In spite ofthe grow- viability of the treatment options, a review of the bio-
ing interest, most surgeons still.believe that I) metal logical research is necessary.
should not be used in contaminated wounds'? and 2)
once an infection develops in a internally stabilized Foreign-Body Effect of Implant
fracture, the metal must be removed before resolution
of the infection can occur. 6-8 However, others believe In orthopedics and oral and maxillofacial surgery,
that such materials do not need to be removed from many have emphasized the "foreign-body effect" of a
infected sites if rigidity is maintained.v!' Rigid internal metal implant.7 ,10,15 Difficulty exists in accurately de-
fixation has even been called the superior treatment termining the biological influence of a foreign body,
for infected mandible fractures. 14 because when an implant is placed, surgical trauma is
When treating infected mandibular fractures, two inevitably inflicted. If an infection then develops, it is
goals exist: 1) resolution of the infection and 2) difficult to determine whether the implant or the sur-
achievement of bony union. Those advocating MMF gical trauma and contamination caused the infection.
or external fixation believe elimination ofthe infection
must occur before bone union occurs. Those using in- Implants Placed Into Clean Wounds
The closest approximation ofthe risk assumed solely
Received from the Division of Oral and Maxillofacial Surgery, by the addition ofan implant to the body is seen when
The University of Texas Southwestern Medical Center, Dallas. placement occurs with minimal soft tissue and vascular
• Resident. trauma during a sterile elective procedure. Such is the
t Associate Professor.
Address correspondence and reprint requests to Dr Ellis: Division case with prosthetic joint replacement. Insall et al re-
of Oral and Maxillofacial Surgery, The University of Texas South- ported three deep infections in 220 arthroplasties for
western Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75235- total knee replacements." Similarly, Kaufer and Mat-
9031.
thews reported three deep infections in 373 total knee
© 1992 American Association of Oral and Maxillofacial Surgeons replacements.'? Other orthopedic studies have yielded
0278-2391/92/5005-0002$3.00/0 similar rates of infections when implants are placed
434

2. KOURY AND ELLIS 435
into sterile atraumatic wounds.P:'? showing an ex- Varying results have been found in comparative
tremely low incidence of infection under these con- studies. Most studies in the orthopedic literature that
ditions, in spite of the fact that these implants move have been performed over the past 30 years show that
under function. when similar injuries are compared, no major differ-
In cases of closed long-bone fractures, the infection ences in the rate of infection are found between those
rate is not appreciably greater with internal fixation treated with open reduction with or without internal
than with closed reduction. For example, Burri,'? Ole- fixation devices. 3 1•36 Although some studies have shown
rod and Karlstrorn." and Allgower" reported infection increased rates of infection for open (contaminated)
rates in closed fractures of 0.18% in 744, l.l% in 91, fractures treated with internal fixation when compared
and 1.4% in 720 fractures, respectively. Comparable with open reduction without internal fixation, most of
rates of infection have also been shown between closed these used internal fixation in wounds where the blood
techniques and blind intramedullary nailing. 22,23 supply was greatly disturbed.F:"
Soft-tissue injury has been shown to be a primary
Implants Placed Into Contaminated Wounds factor in infection rates with internal fixation of con-
taminated fractures. Chapman and Mahoney showed
A difference in the rate ofinfection between implants a 1.9% infection rate with mild soft-tissue trauma, 8%
placed in clean and in contaminated wounds was dem- with moderate trauma, and 41 % in severe soft-tissue
onstrated by Rittmann et al. 24 Open and closed tibial trauma of open fractures." Edwards similarly dem-
fractures were treated with open reduction and internal onstrated this point and showed the infection rate of
fixation with compression plates. He found a 1.8% in- internally fixed fractures could be greatly reduced by
fection rate in the closed (noncontaminated) fractures not extending the wound when placing the fixation."
and a 6.3% in the open (contaminated) fractures. Like- In dogs, he also found a decrease in the incidence of
wise, Burri, in a study of 744 fractures, reported an osteomyelitis when no soft-tissue damage was produced
infection rate of 0.18% in closed and 2.7% in open when similar bony fractures were created. These studies
fractures treated with internal fixation.'? Towers also may indicate that once contaminated, a fracture treated
noted an increased rate of infection in open (contam- with open reduction may be better off with an internal
inated) fractures and believed fewer bacteria were fixation device as long as the vasculature and soft-tissue
needed to produce clinical infection with metal implant bed is not significantly jeopardized by the additional
placement." surgical exposure during implant placement.
The body may have difficulty with bacteria in the Overall, the fractured mandible should be very sus-
presence ofimplants because biomaterials are a suitable ceptible to infection because of their great tendency to
substrata for their growth." Removal of fixation ap- be of the open variety. Mucosal tears and fractures
pliances from infected wounds unresponsive to anti- extending through the periodontal ligament produce
biotics has revealed bacterial colonization on their sur- contamination of the fracture by the oral flora. 12 Most
face. 26 A bacterial biofilm has also been shown on fractures that occur through the tooth-bearing area can
orthopedic implants." This surface slime, or glycolax, therefore be regarded as contaminated. Further, sur-
is made from carbohydrates of the bacterial cell wall" gical intervention through the poorly cleanable oral
and is believed to increase the incidence of infection, cavity further contaminates the wound. Of interest,
to provide a barrier to macrophage and antibiotic pen- however, is the finding that a foreign body firmly at-
etration, as well as to prohibit the culturability of these tached to bone does not greatly increase the danger of
bacteria.P Also, spread of bacteria down nonreactive infection in the mandible.F:" In fact, Luhr et al found
biomaterials into noncolonized areas has been fewer infections using an intraoral approach (3.2% in-
shown. 29 ,3o In effect, biomaterials alter the body's de- fection) to place fixation devices than when using the
fense and provide a surface for bacterial adherence and extraoral approach (5.6%).42 The explanation for these
colonization." findings is not clear, but P9ssibly rests with the lush
Thus, there is a difference in the rates of infection vascularity in the maxillofacial region.
between placing implants in closed (clean) and in open
(contaminated) fractures. A comparison must be made, Effect of Mobility on Infection
however, between the use of internal fixation devices
and not using them when treating contaminated (open) Internal fixation has been called the superior treat-
fractures. In other words, when a contaminated fracture ment for infected mandibular fractures," partly be-
requires open reduction, does the use of implants alter cause the biological reaction to mechanical influences
the rate of infection? Answering this question allows plays an important role in local infection.P Many
one to weigh the risk of the foreign body versus the studies have shown that instability promotes infection,
benefit of stabilization of the bony fragments and the and stability helps prevent it. 9 , 11. 13, 19,44-46 Friedrich and
soft-tissue bed in the presence of bacteria. Klaue showed a correlation between the presence of

3. 436 RIGID INTERNAL FIXATION FOR INFECTED MANDIBULAR FRACTURES
osteitis and lack of rigidity in rabbit long-bone fractures tion under these circumstances.Y Insall et al 1 and 6
by injecting staphylococcus aureus into rigidly or non- Kaufer and Matthews'? each had three deep infections
rigidly fixed sites.'? The group of mobile fractures with 220 and 373 arthroplasties, respectively, that re-
without bacterial infection did not become infected, quired implant removal for resolution, but many in
showing that even with mobility contamination must orthopedics believe metal implants that provide sta-
occur to produce an infection. With mandibular frac- bility should be left in place and only the unstable ones
tures, surgeons have made similar suggestions regarding should be removed. I1.19.20 Hicks believed infection was
the effect of mobility on the rate of infection. 12,47.48 easy to overcome with rigid internal fixation."
Although several authors have stated that implants
Effect of Infection on Bone Healing must be removed to resolve infection in the mandible,
clinicians have shown resolution without removal as
Several authors have shown that bone union can long as the fixation was stable. Johansson et al reported
take place in the face of infection both experimentally 42 infected mandibular fractures treated with mini-
and clinically.IO·II,13,44,49,so For instance, all of Macaus- plates." Twenty-four percent of the infections persisted
land and Eaton's 14 postoperative septic long-bone postoperatively. Six of nine resolved, whereas in the
fractures treated with intramedullary rods achieved remaining three the fixation devices were removed be-
bony union even though infection was present."? He cause of instability. Beckers showed resolution of all
believed complete immobilization promoted osseous 19 infected mandibular fractures he treated with in-
union. Similarly, Souyris et al reported 25 cases of ternal fixation." Others also have found resolution of
mandibular fracture treated with internal fixation that infection with plates in place when the fractures re-
became infected in the early postoperative period." mained stable. 12,52,53,s6-s8 On the other hand, when
The plates were left in place for several weeks and, on plates or screws were loose, infections persisted until
removal, the bone was found to have healed. Johansson the loose implants were removed. s2,s3,57,59,60
et al,s2 Prein and Schmoker." and Beckers" have
shown similar results. Johansson et al found primary Overview
bone healing in 76% of cases where infection was
present.V The findings from the short review presented led
Experimental verification of bone union in the face to the following conclusions regarding placement of
of infection was offered by Rittmann and Perren. II fixation devices into contaminated wounds: 1) the risk
They conducted osteosynthesis on sheep femurs and ofinfection following open reduction may be no greater
infected the stable hone-plated fractures with staphy- than when a device is not placed; 2) bony union can
lococci over a period of 8 weeks. All showed bony union occur in the face ofinfection as long as immobilization
over this period, some of which" was primary, despite of the fractured segments is maintained; 3) resolution
the clinical infections. The study by Friedrich and of infection can occur even when a plate is present; 4)
KIaue of rabbit long-bone fractures stabilized internally if resolution of an infection does not occur in a fracture
and infected with Staphylococcus aureus also showed treated with internal fixation, one must verify that the
that primary bone union occurred in the face ofinfec- fixation is rigid; 5) if resolution of an infection does
tion as long as the osteosynthesis was stable.':' not occur in a fracture treated with stable internal fix-
Conversely, mobility of an infected fracture is not ation, one can usually leave the plate for 8 to 12 weeks
well tolerated. Meyer et al treated 214 cases of osteo- to achieve bone union, and then remove it to allow
myelitis after operative treatment of fractures; 45 of rapid resolution of the infection.
49 fractures that had unstable fixation resulted in non- Given these findings, we developed a simple protocol
union." Furthermore, in the presence of infection, for treating infected fractures with internal fixation in-
nonsurgical treatment may not be effective because of tending not to remove the plates. Choice of treatment
the lack of rigidity, as demonstrated by Nicol1.54 He is predicated on the extent of the infection. If a patient
treated 22 infected long-bone fractures nonsurgically, presents with a mild to moderate cellulitis or a spon-
with a resulting 60% incidence of delayed union or taneously draining abscess, the patient is treated by
nonunion. open reduction and internal fixation, with placement
of a drain for postsurgical irrigation with saline. Intra-
Infection Following Osteosynthesis venous antibiotics are given in the perioperative period.
If a patient presents with a severe cellulitis or closed
Once an infection develops in a fracture stabilized (nondraining) abscess, the patient is treated as any pa-
with internal fixation, can one obtain complete reso- tient with an infection, with intravenous antibiotics
lution of the infection with the implant in place? Many and incision and drainage in the case of an abscess.
clinicians in orthopedics and maxillofacial surgery have After 3 to 4 days, the patient is taken to surgery for
stated that implants must be removed to resolve infec- open reduction and internal fixation of the fracture. A

4. KOURY AND ELLIS 437
drain is left following surgery for continued saline ir- bacterium. Two days later, with gross purulence absent, the
rigation. In either of the preceding courses oftreatment, drain was removed and the patient was taken to the operating
room and given cefazolin (I g every 6 hours). Under general
any other potential cause for the infection, such as a
anaesthesia, an intraoral incision was made and granulation
devitalized tooth, is eliminated as soon as possible. tissue was removed from the fracture site. Arch bars were
We have used this protocol for the past 2 years and placed, MMF secured, and a bone clamp was used to reduce
have found it to be effective. Frequently, owing to the fracture. A six-hole reconstruction plate was placed in-
scheduling difficulties, the timing of surgical interven- traorally in a noncornpressive manner along with a Penrose
tion may be expedited or delayed, but we generally drain; the MMF was then released (Fig IB). Four days later,
the antibiotic was changed to ticarcillin/clavulonate (3.1 g
attempt to institute the protocol described. Two cases every 6 hours). Slight purulence was noted at this time, but
representative ofour experience with placement of rigid stable fracture segments and occlusion were present. The fol-
internal fixation in infected mandibular fractures are lowing day, an intraoral communication was noted but the
presented. Nine additional cases are presented in Table wound was free of purulence and granulation tissue was
I. Contrary to previously reported cases, the fixation forming at the wound site. After drain removal the following
day, the patient was given amoxicillin/clavulonate (500 mg
devices were not removed. every 8 hrs) and discharged. Ten days later the patient re-
turned to the clinic without complaint. At this time he had
a good range of motion, normal sensation in his lower lip,
Report of Cases and resolution of the swelling. The arch bars were removed
that day. The patient was seen 26 weeks following fracture
Case 1 and was found to be doing well. His occlusion was normal
(Fig IC), and the fracture had healed completely with no
A 31-year-old woman was struck in the face several days signs of residual infection (Fig ID).
prior to seeking care. The patient had poor oral hygiene,
malocclusion (Fig IA), submental space abscess (Fig IB),
mobility between the first premolar and canine, and an in-
Additional Cases
terincisal opening of 30 mm. Radiographic evaluation re-
vealed a minimally displaced left body fracture and a mod- Nine additional cases are presented in Table l. All
erately displaced right subcondylar fracture (Fig IC). The of these cases were treated by 2.7-mm bone plating
patient was admitted to the hospital and treated with intra- systems. Follow-up in all cases showed resolution of
venous penicillin G (2 million units four times hourly). Two
infection, stability across the fracture to bimanual pal-
days later, she was taken to the operating room, where an
incision and drainage of the' submental abscess was per- pation, good occlusal relationships, and no clinical or
formed, followed by application ofarch bars and MMF. The radiographic signs of nonunion.
fracture in the mandibular body was opened transorally and
rigidlysecured with the placement ofa six-hole reconstruction Discussion
plate at the inferior border of the mandible after the removal
ofa small sequestrum (Fig ID). A Penrose drain was placed
through the extraoral incision and drainage incision into the The cases presented support the findings of other
subperiosteal space (Fig IE). No postsurgical MMF was used. authors in orthopedics9,I1,2o,46,49 and oral/maxillofacial
Two days later, with the patient progressing well and with surgeryl2,14,52,58 where internal fixation has been used
no purulent drainage, the drain was removed and she was to treat infected fractures. The majority ofthese authors
discharged with a prescription for cephalexin (500 mg four
removed the fixation appliance after bony union oc-
times daily). At this time, the patient had moderate swelling
around the chin. By the following week the swelling had re- curred. We have found that fracture union and reso-
solved. Eight weeks later, the patient had an interincisal lution of infection can be accomplished without re-
opening of45 mm and was without complaint. The arch bars moval of the plate. Using our experience in the
were subsequently removed and 55 weeks after injury she treatment of infected fractures with rigid internal fix-
was doing well without further complications (Figs IF,IG).
ation and those fractures that had become infected fol-
lowing application of rigid internal fixation, we devel-
Case 2 oped a protocol for treating infected mandibular
A 32-year-old man sustained a fracture of the mandibular fractures.
symphysis 3 weeks prior to coming to the emergency de- As with any patient, a careful history and physical
partment. He complained of swelling and draining pus. lie examination are performed. After the diagnosis is
was afebrile, had submental swelling with extensive overlying
made, the patient is given antibiotics, preferably intra-
erythema, and had a sinus tract in the submental area that
occasionally drained spontaneously. Intraorally, the mucosa venous, and is usually admitted to the hospital. A de-
was open, with exposed bone. An occlusal step was apparent cision must then be made whether to treat the infection
on the left side, and the left lower lip was anesthetic. A di- before reduction and internal fixation of the fracture.
agnosis of open, infected, minimally displaced mandibular This decision is predicated largely on the basis of the
symphysis fracture was made (Fig 2A). The patient was ad-
vascularity of the region and severity of the infection.
mitted to the hospital, treated with intravenous penicillin G
(2 million units every 4 hours) and a submental incision and The vascularity of the tissue has been found to be ex-
drainage was done. Initial cultures revealed coagulase-positive tremely important for preventing and overcoming an
staphylococcus, clostridium, peptostreptococcus, and fuso- infection, especially in the presence of an avascular

5. ~
(j.)
ex>
Table 1. Cases of Infected Mandibular Fractures Treated With Rigid Internal Fixation
Age Infected Duration of Previous Treatment Rendered for
Patient Sex (yr) Fracture Infection Treatment Type of Infection Infected Mandibular Fracture Follow-up (wk)
3 F 29 Symphysis 1 wk Oral PCN X I wk Nondraining abscess IV PCN, simultaneous I/O I & 17
prior to with overlying D and ORIF with four-hole
presentation cellulitis in compression bone plate, E/ ;;0
submental space o drain; drain removed 2 d s
postop; DC 2 d postop; at 7 S
d, readmission with
submental infection; IV ~
m
;;0
amoxieillin, E/O I & D, E/O z
drain placed;drain removed >
[""
2 d postop; DC 3 d postop
74
:!l
4 M 3 Rt angle >1 mo Closed reduction Spontaneously draining 6 d of IV PCN; simultaneous X
of same (I/O) submandibular E/O I & Dand >
-l
fracture 5 mo space abscess, debridement, ORIF with 0
before; no sequestra formation eight-hole noncornpression Z
follow-up reconstructive bone plate,
.,.,
0
extr no. 31, E/O drains; ~
drains removed 5 d postop; Z
DC6 d postop ril
5 M 27 Lt angle 3 wk Oral PCN X I wk Spontaneously draining IV ccphazolin, E/O I & D and 21 ::J
tn
prior to (I/O) subperiosteal ORIF with noncompression C
presentation abscess at eight-hole reconstructive
mandibular angle bone plate + four-hole 2-
z
>
. mm plate at superior Z
C
border, E/O drains; drains tii
removed I d postop; DC 2 e
d postop !;:
;;0
6 M 33 Symphysis 2wk None Localized cellulitis and IV PCN,I/O I & D and ORIF 15
swelling with
erythema of
with seven-hole
noneompression
~
submental skin reconstructivebone plate, ::J
c
no drain placed; DC same ~
day I3l

6. 7 M 28 Lt body 3d ORI F with lag Localized alveolar IV PCN, I/O I & D, hard ware 20 ~
swelling, 0
screw and 2· removal (hardware was c:
mm bone plate spontaneous- loose), sequestrectomy, and :;0
of fractur e 5 draining (I/O ) ORIF with six-hole
-<
wk earli er submandibular space noncompression
>
Z
ab scess, non un ion of reconstructive bone plate, 1/ 0
tTl
fx o drain; drain removed 2 d r-
r-
postop; DC 4 d postop Vi
8 M 33 Rt body 2 wk Non e Spontaneous-drainin g IV PCN, E/O I & D and ORI F 13
(I/O ) submandibular with eight-hole
space abscess noncom pression
reconstructive bone plate,
E/O drains; drain remo ved
2 d postop; DC 3 d postop
9 F 34 Rt bod y 5 wk Closed reduction Spontaneous-draining IV PeN, E/O I & D and 14
of fracture 6 (I/O ) subm and ibula r sequestrectomy. ORIF with
wk earlier space abscess, seven-hole noncomprcssion
sequestra formation reconstructive bone plate.
E/O drains; drain removed
2 d postop; DC 3 d postop
10 M 32 Rt angle 3 wk ORI Fof same Spon taneous-drainin g IV PCN, E/O I & D and 31
fracture 5 wk (I/O) subm andi bular seq uestrectomy, ORIF with
prior with two space abscess, eight-hole noncom pression
2-mm plates sequest ra format ion reconstructive bone plate,
E/O drains; drain removed
3 d postop ; DC 4 d postop
II M 28 Lt a ngle 1 wk None Submandibular/ IV PeN. E/O I & D a nd ORI F 16
subperiosteal abscess with eight-hole
lateral mand ible. noncom pression
fluctuant reconstructive bone plate.
E/O drains; drains remo ved
2 d postop; DC 3 d postop
All bone plates were appli ed with 2.7-mm bone screws.
Abbreviations: E/O . extraoral ; I/O , intraoral; I & D. incision a nd drainage; PCN, penicillin G ; ORIF, open reduction and internal fixat ion; DC, discharge.
.j:Io.
c.:l
<0

7. 440 RIGID INTERNAL FIXATION FOR INFECTED MANDIBULAR FRACTURES
B
FIGURE I. Patient with infected mandibular symphysis fracture. A. Malocclusion. B. Submental abscess. C, Panoramic radiograph of patient
showing symphyseal fracture and right subcondylar fracture. E, Six-hole reconstruction bone plate used to stabilize the fracture. Note small
piece of bony sequestrum in forceps (below). D, Immediately postsurgery, showing Penrose drain in place. F. Occlusal relationship at 55 weeks
postsurgery. G, Panoramic radiograph at 55 weeks postsurgery.

8. KOURY AND ELLIS 441
AGURE 2. Patient with infected mandibular symphysis fracture. A. Panoramic radiograph showing fracture. B. Intraoperative photograph
showingfracture reduced with a reconstruction bone plate. C. Occlusionat 26 weekspostsurgery. D, Panoramic radiograph 26 weekspostsurgery.
implant. 33,38,4o,61,62 If there is only a mild to moderate step necessitates the removal of teeth in the line of the
cellulitis or a spontaneously draining abscess, we per- fracture that are indicated for extraction,52,53.63 curet-
form the open reduction and internal fixation as soon tage of granulation and infected soft tissue, sauceri-
as our operating room schedule permits. Drains are zation and sequestrectomy of dead bone, and the re-
placed if gross purulence is noted intraoperatively. If moval of nonfunctional foreign bodies. 7.9,44,46,64
severe cellulitis is present, intravenous antibiotics are Second, if drains are deemed necessary due to the pres-
given until the tissue pressure has decreased to allow ence of purulence in the wound at the time of surgery,
improved perfusion of the area for better healing and they must be kept in place until the wound stops pro-
resolution of the infection. Likewise, if copious purul- ducing such drainage. 46,52 The drains allow the wound
ence has caused extensive tissue dissection and abscess to be irrigated and also prevent the build-up ofabscess
loculations, implant placement may be best accom- cavities that the body is unable to fight efficiently. One
plished a few days after incision and drainage to relieve should not be too quick to remove the drains in such
the tissue tension. Any devitalized teeth are removed patients. Third, absolute rigidity is essential. Rigidity
as early as possible. In such cases, the drains are irri- has been shown to produce a stable foundation for soft-
gated four times daily. Once the swelling and purulence tissue growth " so that vascularity to the area can im-
have decreased, the patient is taken back to the oper- prove and the wound can heal." Avascularity has been
ating room for open reduction and rigid fixation. Sim- shown to be one of the primary risk factors for infec-
ilarly, infected wounds with a large area of necrotic tion. 37,39 Rigidity has also been shown to prevent bac-
and avascular tissue and comminuted fragments, such teria from being continually pumped through the frac-
as infected gunshot wounds, may be better treated ture site, thereby decreasing the chance of osteitis.'?
without extensive surgical intervention until the infec- One must remember that osteolysis occurs in the pres-
tion begins to resolve and viability of the soft tissues ence of infection, which can weaken the bone sur-
is established. Typically, when surgery is delayed, it is rounding the screws. I 1,13 This increases the possibility
usually performed approximately 3 to 4 days following of fragment mobility and delayed bone healing. Be-
incision and drainage. cause of these considerations, greater rigidity is nec-
When using rigid internal fixation devices for in- essary. We most commonly employ heavy reconstruc-
fected mandibular fractures, three points should be tion bone plates with 2.7-mm bone screws to secure
borne in mind. First, adequate debridement of infected such fractures. In the mandibular angle region, and
tissue is essential for resolution of the infection. to This usually elsewhere in the mandible, three screws are

9. 442 RIGID INTERNAL FIXATION FOR INFECTED MANDIBULAR FRACTURES
placed on each side of the fracture to assure firm fix- This treatment is not proposed as a replacement for
ation. When the bone fragments have not been eroded more traditional methods. Both external fixation and
by the infective process, we may employ the use of MMF have stood the test of time and proved their
compression osteosynthesis. Compressing the bone effectiveness. Rather, plate and screw fixation is a viable
fragments provides more rigidity for a given number option that allows the patient the same benefits that
of bone screws." Compression also helps reduce the its use in noninfected fractures provides. It is very useful
fracture gap,65 thus decreasing the chance of osteitis in the noncompliant patient who frequently will not
and the progression of the infection.I':'? In 1979, tolerate MMF.
Beckers" reported 14 infected fractures in which four
of five treated without compression developed post- References
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Discussion
Rigid Internal Fixation for the Treatment fixation applied according to established biomechanical
of Infected Mandibular Fractures principles have been well documented.' Early, pain-free mo-
bilization of the mandible without jeopardizing healing has
come to include application of these techniques in recon-
Daniel Buchbinder, D/lfD, and structivc and orthognathic procedures as well as in the treat-
William Weber, DMD ment of infected fractures'" and delayed treatmcnr'" of non-
The Mount Sinai School ofMedicine and Medical Center, infected fractures. Reports of early immobilization as a
Nell' York prerequisite for considering RIF have been unconvincing.t
Cases for rigid internal fixation, like any other treatment;
The authors' presentation of II cases of open reduction must be carefully selected. As the authors suggest, it should
and rigid inlernal fixation (RIF) of infected mandibular frac- be strongly considered in the treatment of noncompliant pa-
tures using their treatment protocol further shows the use- tients who will not tolerate MMF. Although many cases of
fulness and, when properly performed, efficacy of RIF in infected fractures may involve a noncompliant patient pop-
maxillofacial traumatology. The benefits of absolute rigid ulation, some infected cases are the result oftreatment delayed