CRANIOMAXILLOFACIAL TRAUMA

A Detailed Analysis of Mandibular

Angle Fractures: Epidemiology,
Patterns, Treatments, and Outcomes
Neel Patel, DMD, MD,* Beomjune Kim, DMD, MD,y and Waleed Zaid, DDS, MScz
Purpose:

The purpose was to analyze mandibular angle fractures by examining epidemiologic trends
and mechanisms of injury and to determine whether a statistically meaningful relation existed between
certain treatment modalities and patient outcomes.

Materials and Methods:

A retrospective chart analysis was performed, and data were limited to 1 operator. Treatment variables were methods of fixation, postoperative intermaxillary fixation (IMF), and retention versus extraction of teeth in the line of fracture. Outcomes were rates of postoperative infection,
fracture healing, and overall patient comfort. Analysis was performed using the Fisher exact test, Wald
test, and c2 test, with a P value less than .05 considered significant.

Results:

One hundred three patients were included in this study. The mean age was 30.4 years, most
patients were men, and most injuries occurred during physical altercations and on the left side of the
face. The most common concomitant fracture was of the contralateral parasymphysis. A statistically meaningful relation was noted between methods of fixation and healing and overall patient comfort, with the
Champy technique and reconstruction plate being associated with the highest rates of bony union and
patient comfort. No statistically relevant correlation was found between methods of fixation and rates
of infection. There was no statistically relevant link for extraction versus retention of healthy teeth in
the line of fracture or use of IMF with patient comfort, postoperative infection, or fracture healing.

Conclusion:

Although the Champy technique and reconstruction plates were associated with better
postoperative outcomes, such as patient comfort and fracture healing, these should not be used interchangeably. IMF and extraction versus retention of teeth in the line of fracture did not influence any of
the outcomes.
2016 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 74:1792-1799, 2016

Mandibular angle fractures (MAFs) are among the most

common maxillofacial injuries; they are associated
with the highest complication rates of all mandibular
fractures, yielding an incidence as high as 32%.1-4
These fractures are frequently associated with facial
lacerations (32%), cervical spine injuries (2 to 10%),
orthopedic injuries (20%), neurologic injury (24%),
and thoracic and abdominal injuries (12%).5-9 The
MAF is defined as a fracture line that begins where

the anterior border of the mandibular ramus meets

the body of the mandible and extends inferiorly
through the inferior border or posteriorly toward the
gonial angle.10 Fracture osteosynthesis is widely
considered the standard treatment of these fractures;
however, controversy remains regarding the ideal
treatment modality of MAFs. Management of such fractures is difficult because of the complex biomechanics
of the mandibular angle, such as the attachment of the

Received from the Department of Oral and Maxillofacial Surgery,

Maxillofacial Surgery, 1100 Florida Avenue, Box 220, Room 5303,

Louisiana State University Health Sciences Center, New Orleans, LA.

New Orleans, LA 70119; e-mail: npate9@lsuhsc.edu

*Resident.
yAttending Surgeon.

Received February 25 2016

Accepted May 5 2016

zAttending Surgeon.

2016 American Association of Oral and Maxillofacial Surgeons

Conflict of Interest Disclosures: None of the authors have any

0278-2391/16/30134-3

relevant financial relationship(s) with a commercial interest.

http://dx.doi.org/10.1016/j.joms.2016.05.002

Address correspondence and reprint requests to Dr Patel: Louisiana State University Health Sciences Center, Department of Oral and

1792

1793

PATEL, KIM, AND ZAID

masticatory muscles exerting their forces in different

vectors, having a thin cross-sectional area, the abrupt
change in curvature, and the presence of
third molars.11
Likely the most important point of controversy
over the years has concerned which type of fixation
constitutes the most ideal treatment, particularly the
use of 1 miniplate versus 2 miniplates in the treatment of MAFs. Some studies have reported a decrease
in the rate of complications with the use of 1 miniplate,12-15 whereas others have found that the use
of 2 miniplates actually offers a more stable method
of fixation with less stress at the fracture site.16
Schierle et al17 reported no difference when using
1 versus 2 miniplates in the treatment of MAFs,
whereas others have found that 2 plates are a superior form of management and that 1 miniplate actually yields a higher rate of complications.18
According to the authors literature search, there
was no published study that comprehensively looked
at multiple treatment variables, including methods of
fixation, use of postoperative intermaxillary fixation
(IMF), and retention versus extraction of teeth in
the line of fracture, and compared them with multiple patient outcomes, such as rates of postoperative
infection, fracture healing, and overall patient comfort, to determine whether a statistically meaningful
relation existed between them. This information
could improve future patient care.

Materials and Methods

An institutional review board proposal was formulated and approval was granted by the institutional
review board committee associated with the authors
institution for their proposed study. A retrospective
chart analysis of 103 patients was conducted, and
data were collected using International Classification
of Diseases, Ninth Revision codes, specifically 802.20
(closed fracture of mandible, unspecified site), 802.25
(closed fracture of mandible, angle of jaw), 802.30

Table 1. STUDY CRITERIA

Inclusion

Exclusion

Age >18 yr
Complete edentulism
Partially or fully dentate Previous mandibular trauma
Minimum 6-wk
Infected mandibular fracture
follow-up
Pre-existing mandibular
pathology or pathologic
fracture
Immunocompromised patients
Patel, Kim, and Zaid. Analysis of Mandibular Angle Fractures.
J Oral Maxillofac Surg 2016.

(open fracture of mandible, unspecified site), and

802.35 (open fracture of mandible, angle of jaw).
The inclusion and exclusion criteria for this study are
listed in Table 1.
All patients included in this study were treated by 1
surgeon, thus eliminating inter-operator variability,
which removes operator bias when choosing a
treatment modality for any given injury. Epidemiologic
data were divided and analyzed based on age, gender,
time of year that the injuries occurred, mechanism of
injury, location and laterality of injuries, and other
concomitant mandibular injuries. Then, the relation
among 3 different treatment variables and 3 specific
patient outcomes were examined to determine
whether a statistically relevant correlation existed.
First, the authors studied multiple types of fixation,
namely the single superior lateral border plate, the
Champy plate, the strut or ladder plate, the 2-plate
technique including 1 superior lateral border plate
and 1 inferior border plate, the single inferior border
fracture plate, and the single reconstruction plate. Second, the authors studied the use of IMF postoperatively using Erich arch bars with IMF wires or elastics
or IMF screws with wires or elastics. Third, the authors
studied teeth in the line of fracture and whether these
were retained or extracted as a part of the treatment.
The teeth were divided based on their position and recorded as fully erupted, partially bony impacted, or
fully bony impacted. It is important to note that only
un-fractured and uninfected teeth with no associated
pathology were included in this study. For patient outcomes, 3 of the most important outcomes were
included in this study. First was the occurrence of postoperative infection, which was defined as erythema,
tenderness or pain, with or without the presence of
purulent discharge at the site of surgery at the mandibular angle intra- or extraorally. Second was fracture
healing achieved with the treatment; this was divided
into complete bony union, malunion or fibrous union,
and nonunion. Healing was determined in 3 ways:
radiographically (as cortical continuity and progressive diminishment of the fracture line within 6 weeks),
clinically at follow-up visits by performing a thorough
physical examination with attempts to challenge the
fracture while noting any mobility between fracture
segments, and at the time of treatment of complications under direct visualization during surgical exploration. Third, the authors looked at overall patient
comfort; this was determined using an analog pain
scale of 1 to 10. A score of 1 to 3 signified good overall
patient comfort; a score of 4 to 7 was classified as moderate patient comfort; and a score of 8 to 10 was
deemed a poor overall patient comfort level. Analysis
was performed using the Fisher exact test, Wald test,
and c2 test, with a significant correlation being a
P value less than .05.

1794

ANALYSIS OF MANDIBULAR ANGLE FRACTURES

Results

Gender Distribution

In the present study, 103 patients were included based

on the inclusion and exclusion criteria listed in Table 1.
EPIDEMIOLOGIC DATA

Age Distribution
The mean age of patients included in this study was
30.4 years (range, 18 to 64 yr). The highest incidence
of MAFs was in the third decade of life and the lowest
incidence was in the seventh decade (Fig 1).
Gender Distribution
The vast majority of patients were men (Fig 2),
comprising 85 of 103 patients (82.5%), whereas
women accounted for just 18 of 103 patients (17.5%).
Monthly Variation
In regards to the time of year that these injuries
occurred, the highest incidence was in the month of
June, with 17.5% of injuries occurring during that
month. The lowest incidence was in the month of
May, with only 1% (Fig 3).
Mechanisms of Injury
The overwhelming majority of injuries resulted from
physical altercations, with fists being the weapon of
choice in 88 of 103 patients (85.4%; Fig 4). Other mechanisms of injury included motor vehicle collisions (5 of
103; 4.9%), metal object to the face (pipe, firearm, or tire
wrench; 6 of 103, 5.8%), all-terrain vehicle accidents (2
of 103; 1.9%), and sports injuries (2 of 103; 1.9%).
Laterality
In total, 103 MAFs were observed, with most (59.2%)
occurring at the left mandibular angle, 34.9% at the right
mandibular angle, and 5.8% occurring bilaterally (Fig 5).
Concomitant Mandibular Fractures
In total, 153 mandibular fractures were noted in 103
patients included in this study. More than half the

Incidence by Decade of Life

FIGURE 2. Gender variation.

Patel, Kim, and Zaid. Analysis of Mandibular Angle Fractures.
J Oral Maxillofac Surg 2016.

patients had isolated MAFs, occurring in 51.5% of all

patients. The remaining 48.5% patients had at least 1
additional mandibular fracture in addition to the
MAF. Moreover, 4 of these patients had 2 mandibular
fractures occurring concomitantly with the MAF. The
most common mandibular fracture that occurred in
association with MAFs was parasymphysis fractures,
100% of which were on the contralateral side of the
angle fracture (Fig 6). Other fractures that occurred
in conjunction with MAFs were body fractures,
90.9% of which occurred on the contralateral side of
the angle fracture, and subcondylar fractures, all of
which occurred on the contralateral side of the angle
fracture. In the 4 patients who had 2 additional fractures, all were contralateral subcondylar and parasymphysis fractures occurring together. In this
population, no mandibular ramus, coronoid process,
or mandibular alveolar ridge fractures occurred
concomitantly with MAFs.
TREATMENT VARIABLES VERSUS PATIENT OUTCOMES

Methods of Fixation
The first variable analyzed was method of fixation: 1 superior lateral border plate, Champy technique, a strut or ladder plate, a 2-plate technique

Monthly Distribution

FIGURE 1. Incidence by age.

FIGURE 3. Time of year.

Patel, Kim, and Zaid. Analysis of Mandibular Angle Fractures.

J Oral Maxillofac Surg 2016.

Patel, Kim, and Zaid. Analysis of Mandibular Angle Fractures.

J Oral Maxillofac Surg 2016.

1795

PATEL, KIM, AND ZAID

Mechanism of Injury

FIGURE 4. Mechanisms of injury. ATV, all-terrain vehicle; MVC,

motor vehicle collision.
Patel, Kim, and Zaid. Analysis of Mandibular Angle Fractures.
J Oral Maxillofac Surg 2016.

including 1 superior lateral border plate and 1 inferior border plate, 1 inferior border fracture plate, or
1 reconstruction plate. The results are presented
in Table 2.
For fracture healing, a statistically significant difference was seen for union of fractures (P = .0075)
among the different methods of fixation (Table 2).
Use of the Champy technique yielded a 100% incidence of bony union (20 of 20 cases). Moreover, use
of 1 reconstruction plate had a 100% incidence of complete bony union (10 of 10 cases). In contrast, use of
only the inferior border fracture plate for treatment
of MAFs yielded the highest rate of failure (nonunion
rate, 50%). The 2-plate technique was associated
with the highest rate of fibrous unions or malunions
(25%; Fig 7).
The effects of the method of fixation on patient
comfort (Table 3) showed statistical significance
(P = .0033). The fixation that provided the most comfort for patients was the strut or ladder plate (97.14%),

Laterality of MAFs

Other Mandibular Fractures associated

with MAFs

FIGURE 6. Mandibular fractures occurring concomitantly with

MAFs. MAFs, mandibular angle fractures.
Patel, Kim, and Zaid. Analysis of Mandibular Angle Fractures.
J Oral Maxillofac Surg 2016.

followed closely by the Champy technique (95%).

The method of fixation that provided the least comfort
was the 2-plate technique, in which 25% of patients
had the highest level of pain and discomfort postoperatively (8 to 10 of 10; Fig 8). Of note, of patients who
received the inferior border plate, only 50% rated their
postoperative pain level as low, which was the least of
any of the fixation methods, and the remaining 50%
still had a moderate amount of discomfort after
the surgery.
One of the most hotly contended subjects is that
of postoperative rates of infection in relation to
different types of fixation, with much research performed to determine which type has the lowest
rate of infection during the postoperative course.
In the present study, no statistically significant correlation was seen when comparing different methods
of fixation in relation to rates of infection
(P = .0617).
Table 2. EFFECTS OF DIFFERENT METHODS OF
FIXATION ON FRACTURE HEALING

Methods of
Fixation

FIGURE 5. Location of mandibular angle fractures.

Patel, Kim, and Zaid. Analysis of Mandibular Angle Fractures.
J Oral Maxillofac Surg 2016.

Superior lateral
border
Champy
2 Plates
Strut or ladder
Reconstruction
Inferior border

Bony
Union,
% (n)

Fibrous
Union or
Malunion,
% (n)

Nonunion,
% (n)

91.67 (22)

8.33 (2)

100 (20)
75 (9)
94.29 (33)
100 (10)
50 (1)

0
25 (3)
5.71 (2)
0
0

0
0
0
0
50 (1)

Patel, Kim, and Zaid. Analysis of Mandibular Angle Fractures.

J Oral Maxillofac Surg 2016.

1796

ANALYSIS OF MANDIBULAR ANGLE FRACTURES

Effect of Method of Fixation on

Fracture Healing

Effect of Method of Fixation on

Patient Comfort

FIGURE 7. Method of fixation and fracture healing.

Patel, Kim, and Zaid. Analysis of Mandibular Angle Fractures.
J Oral Maxillofac Surg 2016.

Use of IMF
The second treatment variable was the use of postoperative IMF and whether or not this influenced a patients outcome for fracture healing, rates of infection,
and patient comfort. In the present population, the
use of postoperative IMF did not have any statistically
significant influence on rates of infection (P = .5228),
union of fractures (P = .3036), or patient comfort
(P = .1434).
Teeth in the Line of Fracture
The present study found no statistically significant
influence on rates of infection (P = .2047), patient
comfort (P = .5671), or fracture healing (P = .2304)
whether the teeth were extracted or retained, and
regardless of their position in the mouth (erupted,
partially impacted, or fully impacted).

Discussion
Many studies have been performed on the treatment
of MAFs; however, an absolute consensus on the ideal

Table 3. EFFECTS OF DIFFERENT METHODS OF

FIXATION ON POSTOPERATIVE PATIENT COMFORT

Methods of
Fixation
Superior lateral
border
Champy
2 Plates
Strut or ladder
Reconstruction
Inferior border

Good,
% (n)

Moderate,
% (n)

Poor,
% (n)

79.17 (19)

16.67 (4)

4.17 (1)

95 (19)
58.33 (7)
97.14 (34)
70 (7)
50 (1)

0
16.67 (2)
2.86 (1)
20 (2)
50 (1)

5 (1)
25 (3)
0
10 (1)
0

Patel, Kim, and Zaid. Analysis of Mandibular Angle Fractures.

J Oral Maxillofac Surg 2016.

FIGURE 8. Method of fixation and patient comfort.

Patel, Kim, and Zaid. Analysis of Mandibular Angle Fractures.
J Oral Maxillofac Surg 2016.

treatment modality remains elusive. The epidemiology

of such injuries has been changing, with differences in
levels of societal violence, higher urban speed limits,
and larger numbers of sports-related injuries.19,20
The most widely accepted method of treatment for
MAFs has been fracture osteosynthesis; however,
many studies over the years have shown variable
data as to which type of fixation yields the greatest
amount of success, measured by a well-healed fracture
with minimal to no postoperative complications,
while allowing the greatest amount of patient comfort.
In the present study, the largest percentage of injuries
occurred in the third decade of life (21 to 30 yr old;
mean, 30.4 yr overall). These data are comparable
with other epidemiologic studies.14,15 Men
constituted the majority of this patient population
(male-to-female ratio, 4.7:1). Most injuries occurred
because of physical altercations, with more than 85%
of patients being victims of punches to the jaw. A
review of the US National Trauma Data Bank by
Afrooz and Bykowski21 looking at 13,142 cases of
mandibular fractures showed similar results, with
most mandibular fractures (42%) occurring from physical assault. According to the US Department of Justice, which published the National Crime
Victimization Survey in 2006, 77% of assault cases
involved men, with 24.7% of men 21 to 30 years old,
second only to the fourth decade of life at 38.5%.22
Thus, the propensity for men in their 20s to being
the victims of assault, with the consequent injuries,
seems to be higher in the population studied in the
State of Louisiana compared with the national statistical data. Most studies have shown that most injuries
occur in the summer months, as reported by Morris
and Bebeau23 at Parkland Memorial Hospital in a large
retrospective study involving 4,143 mandibular fractures over a 17-year period. The present study showed
a similar finding, with the month of June being the

PATEL, KIM, AND ZAID

most common time of injury. The authors hypothesize

that the warm weather might contribute to this
finding, with a larger number of people engaged in
more outdoor activities compared with other months
of the year. An interesting finding was that more than
half the MAFs were located on the patients left side. As
stated earlier, the overwhelming majority of patients
had their injuries from fists to the face. According to
McManus,24 professor of psychology at University College London, approximately 90% of humans are righthanded, explaining why the left side of the face is the
most common location of injury. Mandibular angle
fractures often are accompanied by other fractures
of the mandibular complex. This is due to the U
shape of this bone; one will often find more than 1
fracture in any given patient and more often contralateral; however, ipsilateral fractures are not uncommon.
The present data showed that parasymphysis fractures
are the most common concomitant mandibular fracture associated with MAFs, and this finding corresponds with what Paza et al25 found in a
retrospective study analyzing 115 MAFs in Brazil
from 1999 through 2004. The present study also found
that the next most common associated fracture is in
the body of the mandible, another parallel to the
same Brazilian study.
The ideal goals of fracture treatment by way of internal fixation is to achieve a stable bony union and
re-establish the premorbid occlusion when applicable and restore preinjury motility and function.26
How to achieve these goals has long been debated
in relation to rigid versus nonrigid fixation. Rigid fixation allows for primary bone healing, which occurs
when the fracture segments have an adequate blood
supply, the segments are immobilized without any
gaps or micromotion, and there is proper alignment
of the fracture segments. Nonrigid fixation, referred
to as functionally stable fixation, in which micromotion between fracture segments is permitted, promotes secondary bone healing when an intermediate
phase of callous formation is present before ossification.26-28 But how do different methods of fixation
influence fracture healing? The authors looked at
this parameter and found some interesting results.
The Champy technique was found to have
achieved bony union in 100% of cases, as did the
use of a reconstruction plate. The highest
nonunion rate was associated with the single
inferior border plate at 50%, although the sample
size for this technique was only 2 cases and thus
does not represent a particularly strong statistic. In
the present study, although there were comparable
success rates of stable bony union using the
Champy technique (which is a nonrigid fixation
modality) and the reconstruction plate (which is
a rigid fixation modality), assuming that these

1797
treatment modalities can be used interchangeably
would not be accurate, and clinical judgment and
experience should be used to select the ideal
method of fracture fixation.
The fear of postoperative pain is very important and
is a common patient concern. The present data suggested that the fixation method that provided the
most patient comfort was the strut or ladder plate, followed closely by the Champy technique. The inferior
border plate, reconstruction plate, and 2-plate technique were associated with the most postoperative
patient discomfort. These results can be explained in
part by the fact that the dissection and exposure
needed to place a reconstruction plate or an inferior
border plate (whether alone or part of the 2-plate technique) often require an extraoral approach, and even if
performed through an intraoral approach, require
larger exposure, dissection, and more stretching of
the tissues to gain access to the inferior border of
the mandible, causing more postoperative pain.
Champy plates, owing to their superior location,
require a more conservative dissection, less periosteal
stripping and tissue stretching, and shorter operating
time with a concomitant decrease in postoperative
discomfort. When comparing the strut with the ladder
plate, this technique also does not require complete
access to the inferior border, because this plate is
placed approximately at the midlateral border, with
the inferior alveolar nerve between the superior and
inferior portions of the plate.
The problem of postoperative infection has long
been debated and represents a major complication
of MAFs. Ellis28 found that the use of a single miniplate at the superior border was sufficient to treat
such fractures, and that the use of 2 plates raises
the incidence of infection dramatically. Conversely,
some of the literature has reported no relevant difference in rates of infection for 1- versus 2-plate techniques.1 Mehra and Haitham29 noted that the use of
fewer plates results in less periosteal stripping,
which can lead to less blood supply disruption, and
decreased operating time, which can decrease the
rate of postoperative infections. A recent prospective
study on MAFs found that the use of a strut plate at
the angle had relatively less or no postoperative complications compared with other techniques.30 Therefore, which method of fixation yields the least
postoperative infections? The present study showed
no statistically meaningful correlation between fixation type and rate of postoperative infection. The differences in rates of infection among various studies
might be attributed to inherent differences in the patient population being studiedvariations in socioeconomic status, differences in tobacco and alcohol
use and abuse, and levels of nutritional status, and
other medical co-morbidities.

1798
IMF has long been used as primary and adjunctive
treatment for mandibular fractures in addition to internal fixation. Champy31 was among the first to report
that the use of a single plate without postoperative
IMF resulted in minimal complications. However,
some researchers believe that placing all patients in
postoperative IMF is beneficial, because IMF might
help form an oral mucosal epithelial seal and allow undisturbed healing of incisions intraorally, help initially
to stabilize the occlusion, particularly in cases treated
with nonrigid fixation, and train the patient to become
accustomed to a liquid diet.29 Valentino and Marantette32 performed a retrospective study in which 499
mandibular fractures were looked at, with 130 patients having postoperative IMF in addition to internal
fixation and the remainder having only internal fixation without IMF, and they found no meaningful effect
on postoperative complication rate in either group.
However, this study only included monocortical fixation. In the population included in the present study,
no relevant link was found between the use of postoperative IMF and fracture healing, occurrence of postoperative infection, or effect on patient comfort.
The presence of teeth in the line of fracture can
complicate the management of MAFs in different
ways. They can impede adequate reduction of the fracture based on their angulation and position and the
location of the fracture line. In addition, some studies
have found that they can increase the risk of postoperative infection. Some investigators have classified the
MAF as an open fracture if the tooth is present,
because of intraoral communication through the periodontal ligament.33 Others have reported that removal
of the teeth decreases the stability of the fracture segments and increases rate of infection. A 1994 study by
Ellis and Walker34 found that the extraction of a tooth
in the line of fracture seemed to increase the rate of
infection; however, in another study published in
2002, Ellis35 reported an increased incidence of infection if teeth were left in the line of fracture. This study
has found no statistically meaningful relation between
removal versus retention of a healthy tooth in the line
of fracture and rates of postoperative infection, patient
discomfort, or fracture healing.
In the present retrospective study, certain methods
of fixation were associated with increased levels of patient comfort and increased likelihood of bony healing.
The use of postoperative IMF and extraction versus
retention of teeth in the line of fracture did not influence any of the outcomes. Although the Champy technique and reconstruction plates were associated with
a statistically relevant increase in postoperative comfort and higher likelihood of bony healing, these modalities cannot necessarily be used interchangeably,
and the surgeons experience and clinical decision
making should be exercised to determine the ideal

ANALYSIS OF MANDIBULAR ANGLE FRACTURES

fixation method on a case-by-case basis. This study

had inherent drawbacks, particularly the use of a retrospective study design. Furthermore, certain confounding factors, such as smoking, were not studied. To
investigate this topic further, a larger prospective clinical trial would be ideal and would likely yield the
strongest data.
Acknowledgment
The authors thank Dr Qingzhao Yu for her contributions to
this study.

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