J Oral Maxillofac Surg

66:73-76, 2008

Analysis of 115 Mandibular Angle

Fractures
Aleysson O. Paza, PhD, MS, DDS,* Allan Abuabara, DDS, and
Luis A. Passeri, PhD, MS, DDS
Purpose: This retrospective study reviewed cases of fractures of the mandibular angle to identify personal

data, social traits, fracture characteristics, treatment modalities, and postoperative complications.
Patients and Methods: From April 1999 until July 2004, 114 patients were treated for 115 fractures
of the mandibular angle by the Division of Oral and Maxillofacial Surgery at Piracicaba Dental SchoolUnicamp, in Brazil.
Results: More angle fractures were observed in Caucasian (55%) men (89%) with some kind of drug
addiction (62%). Patient mean age was 27 years. The majority of fractures in this study were sustained
in altercations, including gunshot wounds (43%), followed by vehicle accidents, including bicycles and
being struck by a car (39%). Open fractures were the most frequent (90%), with prevalence of the left
side (57%). Only 1 patient sustained bilateral angle fractures. Ninety-seven patients (85%) underwent
open reduction. Complications occurred in 19 patients (17%); 10 (9%) were infections. Of the total
number of complications, 3 underwent another surgical intervention for refixation. The factors that
contributed to the development of postoperative complications were social risks that included alcohol
abuse, smoking, and intravenous and nonintravenous drug abuse.
Conclusions: Angle fracture management outcomes are affected by many factors beyond method of
fixation.
2008 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 66:73-76, 2008
Vehicle accidents1 and assaults2-9 are the primary
causes of mandible fractures. Signs and symptoms
include pain and edema, change in occlusion, lower
lip paresthesia, abnormal mandibular movements,
change in facial contour and mandibular arch form,
lacerations, hematoma and ecchymosis, loose teeth,
and crepitation on palpation.10 Panoramic radiographs
and the lateral oblique view of the mandible as well as
computed tomography (CT) scans are the most informative radiologic exams used in diagnosing mandibular fractures.

Fracture treatment can be classified by the method

of reduction, as either open or closed. If open reduction is used, it can be further subclassified into nonrigid and rigid fixation (RIF). Thus, all treatment can
be classified as either mandibular closed reduction
with maxillomandibular fixation (MMF), open reduction with MMF, or open reduction without MMF.11
Mandibular fracture treatment by open reduction and
RIF provides a number of advantages.12-14 The most
obvious is avoiding MMF, which results in an early
return to function, easier maintenance of oral hygiene, improved nutrition, and reduced risk of airway
compromise.15
A displaced fracture in the angle can rarely be
reduced satisfactorily by MMF alone. Therefore, an
open reduction and osteosynthesis are more often
indicated for angle fractures than for other fractures
of the mandibular body. However, several studies
have documented high complication rates after RIF of
the mandibular angle.14,16-18 The purpose of this
study is to review cases of fractures of the mandibular
angle and their associated complications.

*Assistant Professor, Division of Oral and Maxillofacial Surgery,

Joinville University-Univille, Santa Catarina, Brazil.
Specialist in Dental and Maxillofacial Radiology, Health Division, Joinville City Hall, Santa Catarina, Brazil.
Professor, Division of Oral and Maxillofacial Surgery, Piracicaba
Dental School, and Division of Plastic Surgery, School of Medical
Sciences, State University of Campinas-Unicamp, So Paulo, Brazil.
Address correspondence and reprint requests to Dr Passeri: Faculdade de Odontologia de Piracicaba-Unicamp, Av Limeira, 901 Piracicaba, So Paulo, Brazil 13414-903; e-mail: passeri@fop.unicamp.br
2008 American Association of Oral and Maxillofacial Surgeons

Patients and Methods

0278-2391/08/6601-0012$34.00/0

Information was obtained retrospectively from clinical notes, surgical records, and radiographs. From

doi:10.1016/j.joms.2007.05.025

73

74

MANDIBULAR ANGLE FRACTURE

Table 1. DEMOGRAPHIC DATA

Number
Mean age (years)
Gender (%)
Men
Women
Men:women
Etiology (%)
Altercation/assault
Motor vehicle accident
Fall
Bicycle accident
Sports
Gunshot wound
Struck by car
Work accident
Drug action (%)
Alcohol
Tobacco
Nonintravenous drug
Intravenous drug

114
27
101 (89)
13 (11)
7.76:1
45 (39)
31 (27)
12 (11)
10 (9)
6 (5)
5 (4)
3 (3)
2 (2)
71 (62)
58 (51)
42 (37)
18 (16)
1 (1)

Paza, Abuabara, and Passeri. Mandibular Angle Fracture. J Oral

Maxillofac Surg 2008.

April 1999 until July 2004, 114 patients were treated

for 115 fractures of the mandibular angle by the Division of Oral and Maxillofacial Surgery at Piracicaba
Dental School, State University of Campinas-Unicamp,
So Paulo, Brazil. The data recorded included patient
gender, age, etiology, method of surgical treatment,
drug use, and short-term complications. The radiographs were evaluated with respect to the condition
of the reduction, dislocation, relapse of the fixation,
and fracture union. Success was considered if the
fracture fixation provided stability, ie, there was no
interfragmentary mobility, no infection, and no osteolysis/nonunion of the bone fragments.

Results
A higher prevalence of trauma was observed in
Caucasian (55%) men (89%). The patients mean
age was 27 years (range, 16 to 62 years), with some
type of drug addiction (alcohol, intravenous, and
nonintravenous drugs) (62%), and dentate (52%).
The majority of fractures in this study were sustained in altercations (39%), followed by motor
vehicle accidents (27%). Patient demographic data
are shown in Table 1. No relevant medical history
affecting bone healing, notably diabetes, prolonged
steroid therapy, compromised immunity, and associated bony pathology were noted in any of the
patients.
Of the total (114), 97 patients underwent surgery,
all under general anesthesia. Two died before the
surgical procedure, 5 patients underwent surgery at a
hospital that had no affiliation agreement with the

University, and 10 patients did not undergo surgery.

Postsurgical MMF was used in 3 patients treated with
closed reduction, and in 2 patients that had single
miniplate fixation. Antimicrobial and anti-inflammatory drugs were administered for 7 days after all surgical procedures. An antiseptic mouthwash, 0.12%
chlorhexidine, was routinely issued for 7 days. The
cases were divided into 4 groups on the basis of the
methods of fixation (Table 2).
Overall, open fractures were the most frequent,
103 (90%); 12 (10%) were closed; with prevalence on
the left side, 65 fractures (57%); 49 fractures on the
right side (43%); and only 1 bilateral angle fracture
(1%). Isolated fractures of the mandibular angle accounted for 47 patients, and when associated fractures were detected, the mandibular parasymphyseal
fracture was the most prevalent (26 contralateral, 3
ipsilateral) followed by body fractures (20 contralateral, 4 ipsilateral), condylar process (6), and ramus
fractures (1). Other facial fractures occurred in association with mandibular angle fracture: zygomatic
complex (10), nasal (3), Le Fort I (2), and naso-orbitoethmoid (1).
The mandibular third molar was present in 63 fractures (55%). A tooth had been extracted from the
fracture line in 8 patients (Table 3).
The most prevalent clinical signs and symptoms
were asymmetry, swelling, trismus, pain, and change
in occlusion. The time from the initial injury to surgical treatment ranged from 2 and 79 days, with mean
of 11.2 days. Fifty-nine patients (63%) were treated
transorally and 35 were treated extraorally (31%).
Complications occurred in 19 patients (17%), in
which 10 (9%) were infections. Of the total number of
complications, 3 had further surgery for refixation.
The other cases were treated by antibiotics, drainage,
fixation removal, or MMF (Table 4).

Discussion
Fractures of the mandibular angle account for the
highest percentage of mandibular fractures in many
Table 2. TREATMENT MODALITIES

Treatment

Open reduction
1. Monocortical 1-plate, 2.0 mm superior border
(Champy technique19)
2. Mono and bicortical 2-plate, 2.0 mm
3. Bicortical 1-plate, 2.4 mm (inferior border plate)
4. Bicortical 1-plate, 2.4 mm (inferior border plate)
and monocortical 1-plate, 2.0 mm (superior
border)
Closed reduction

94
40
36
12
6
3

Paza, Abuabara, and Passeri. Mandibular Angle Fracture. J Oral

Maxillofac Surg 2008.

75

PAZA, ABUABARA, AND PASSERI

Table 3. STATISTICS ASSOCIATED WITH FRACTURES

OF THE ANGLE OF THE MANDIBLE

Fracture type (%)

Open
Closed
Comminuted and complex
Side (%)
Right
Left
Bilateral
Third molar status (%)
Present
Maintained
Extracted
Absent

103 (90)
12 (10)
9 (8)
65 (57)
49 (42)
1 (1)
63 (55)
55 (87)
8 (13)
52 (45)

Paza, Abuabara, and Passeri. Mandibular Angle Fracture. J Oral

Maxillofac Surg 2008.

studies. The angle of the mandible is associated commonly with fractures, for several proposed reasons,
including the presence of the third molar. Consistent
with Ugboko et al20 and differing from other studies,8,21-24 the results of this study did not confirm an
increased risk of angle fractures when the mandibular
third molar was present (55%); patients reported the
extraction of only 8 (13%) third molars prior to
trauma. However, other reasons, such as the thinner
cross-sectional area than that of the tooth-bearing
region (biomechanically, the angle can be considered
a lever25) and biomechanical forces acting on the
mandible (including the position of insertion of the
masticatory muscles) may influence fracture location.26,27
The group of patients analyzed in this study
showed some interesting features. The most obvious
of these was the high proportion of mandibular angle
fractures that were caused by altercations, including
gunshot wounds (43%). The number of patients considered drug abusers (62%) was also remarkably high.
This showed further evidence of the relationship between drugs and interpersonal violence. The large
proportion of alcohol abusers (51%) in this study may
also be a reflection of the social behavior of this
group.
Treatment modalities were established considering the fracture characteristics. Fractures with 1
line and low displacement of the segments were
treated by the intraoral Champy technique.19 Patients that presented comminuted fractures, large displacement, and considerable injury to the adjacent
soft tissues and parts were treated extraorally, observing AO/ASIF principles. It was apparent that infection
was the commonest type of complication arising from
mandibular fracture treatment. The average rate of
infection ranges between 5% and 10%,10 although
several studies have shown higher complication

rates25 of up to 32% with angle fractures.28 Preoperative oral sepsis, with grossly carious and periodontally involved teeth, contributes to the problem, and
unless decayed teeth are important for reduction and
fixation of the fracture, they should be removed. This
study presented a high complication rate (17%). According to Passeri et al,11 complications are positively
associated with chronic abuse of alcohol and nonintravenous and intravenous drugs (the incidence of
complications was 30% in intravenous drug abusers;
19% in nonintravenous drug abusers, and 15.5% in
chronic alcohol abusers). Individuals who did not
make chronic use of any drug had a 6.2% complication rate. Data analysis showed that of the total, the
number of patients considered drug abusers was the
highest. This may explain the high complication
rate found in this study. Inadequate immobilization of
the fracture segments, prolonged delay in obtaining
treatment contributing to infection, inexperienced
surgeons, no cooperation from patients, and the severity of the trauma may also have contributed to this
high complication rate. Moreover, no difference was
observed between the infection rates of intraoral and
extraoral open reduction procedures.
Another controversy involved the supplementation
of fixation with MMF.29,30 Many surgeons still feel that
miniplate fixation does not provide adequate stability
and required MMF for additional security. In a retrospective study of 287 patients with 499 mandible
fractures, Valentino and Marentette31 compared 130
patients who underwent intraoral monocortical plating of matched fractures and found that the addition
of MMF did not significantly alter complication rates.
Prein et al32 noted similar findings in a small prospective study of 32 patients, combining the old AO technique with MMF. Because the fixation of a fracture
provides absolute rigidity and there is no interfragmentary mobility, MMF is dispensable. In this study, 3
patients were submitted to MMF. In 2 patients, who
had a multiple fracture line, the MMF was used successfully, as an additional precaution and to prevent
complications. In the second patient, who presented
a complicated/complex fracture (with considerable

Table 4. OVERALL COMPLICATION RATES

Complication

Infection responding to treatment

Infection resulting in plate removal
Inferior alveolar nerve paresthesia
Alveolar nerve palsy
Malocclusion
Total

10
5
1
1
2
19

9
4
1
1
2
17

Paza, Abuabara, and Passeri. Mandibular Angle Fracture. J Oral

Maxillofac Surg 2008.

76
injury to the adjacent soft tissues and parts), a monocortical 1-plate 2.0 mm system and postsurgical MMF
were used, because of the unavailability of required
equipment (bicortical 1-plate 2.4 mm). Nevertheless,
a second surgical procedure (dental extraction and
new fixation system) was necessary and the new
fixation method used was a bicortical 1-plate 2.4 mm.
The fixation methods and teeth located in the line
of fracture were not factors in the development of
complications. In agreement with Gear et al,33 for
fractures of the angle of the mandible, the use of a
single miniplate on the superior border of mandible
is simple, reliable, and has become the preferred
method of treatment. Ellis25 made a 10-year review of
various forms of treatment for mandibular angle fracture, as follows: 1) closed reduction or intraoral open
reduction and nonrigid fixation; 2) extraoral open
reduction and internal fixation with an AO/ASIF reconstruction bone plate; 3) intraoral open reduction
and internal fixation using a solitary lag screw; 4)
intraoral open reduction and internal fixation using 2
2.0-mm mini-dynamic compression plates; 5) intraoral
open reduction and internal fixation using 2 2.4-mm
mandibular dynamic compression plates; 6) intraoral
open reduction and internal fixation using two noncompression miniplates; 7) intraoral open reduction
and internal fixation using a single noncompression
miniplate; and 8) intraoral open reduction and internal fixation using a single malleable noncompression
miniplate). The results showed that the use of either
an extraoral open reduction and internal fixation with
the AO/ASIF reconstruction plate, or intraoral open reduction and internal fixation, using a single miniplate, is
associated with the fewest complications, ranging from
0% to 7.5%.25
Severity of the trauma and social risk, which included alcohol abuse, smoking, intravenous and nonintravenous drug abuse, were factors that contributed
to the development of postoperative infection.

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