COMPARATIVE OUTCOMES IN MANDIBULAR ANGLE FRACTURE MANAGEMENT RECONSTRUCTION PLATES VERSUS DUAL MINIPLATES FIXATION 

Moeen Mohammed Ahmed Awad1image, Lutf Mohammed Al-Rahbi1,2image, Ahmed Abdulah Al-Ashwal1,2,5,6image, Hassan Abdulwahab Al-Shamahy3,4image, Khaled Abdulkarim Al-Moyed4image

1Yemen Medical Specialist Council, Ministry of Health and population, Yemen.

2Department of Oral and Maxillo-Facial Surgery, Faculty of Dentistry, Sana’a University, Republic of Yemen.

3Department of Basic Sciences, Faculty of Dentistry, Sana’a University, Republic of Yemen.

4Medical Microbiology and Clinical Immunology Department, Faculty of Medicine and Health Sciences, Sana’a University.

5Member of the consulting Medical Education committee of the Arab Board for Oral and Maxillofacial Surgery.

6Faculty of Dentistry, Emirates International University, Republic of Yemen.

 

Abstract

 

Background and aims: The angle created by the positioning of the ramus and mandibular body is known as the mandibular angle.  An angle fracture is characterized by a triangular region that is enclosed by the masseter muscle's anterior border and an oblique line that runs from the mandibular third molar region to the masseter muscle's posterior inferior attachment.  This study examined the results and side effects of utilizing reconstruction plates against double miniplate fixation for treating mandibular angle fractures.

Materials and methods: The Department of Oral and Maxillofacial Surgery at the Military Hospital in Sana'a, Yemen, carried out the study between 2020 and 2024, diagnosing mandibular angle fractures in two equal groups. Reconstruction plates were used for 20 patients in Group A, and double miniplate fixation was used for another 20 patients in Group B. Following surgery, the two groups had radiographic and clinical evaluations for mandibular deviation, hematoma, infection, limited mouth opening, surgical site edema, plate exposure, plate stability, and malocclusion.

 Results: The study found that 15% of patients treated with reconstruction plates experienced bone exposure, 10% experienced impaired stability, 30% reported plate-site edema, and 15% reported nerve injury, compared to the 10% treated with two miniplates. The study found that the use of two miniplates was better at reducing deviation opening in patients treated with two miniplates, with a difference of 15% and a p-value of 0.07. 

Conclusion: The study found that fixation using two miniplates is the most effective and reliable treatment strategy for mandibular angle fractures, with lower complication rates and minimal infection rates. Further studies are needed to determine the optimal approach for fixing these fractures.

Keywords: Complication rate, double miniplate fixation, mandibular angle fractures, reconstruction plates. 

 

INTRODUCTION

 

The therapy and restoration of mandibular fractures has undergone gradual evolution. Many methods for repairing mandibular fractures have been presented over time. These procedures have varied from maxillary-mandibular fixation (MMF) to combination MMF fixation with bone wire, screw fixation, and plate fixation1-11. The use of compressive and non-compressive plate systems for rigid internal fixation (RIF) has become increasingly common in recent years. Avoiding MMF fixation, early mandibular function, improved patient satisfaction, shortened recuperation times, an earlier return to work, and many other benefits too many to list here are just a few of the advantages of RIF12,13.  

Michelet et al.12, introduced the use of a non-compression unicortical miniplate technique for fixing mandibular fractures about fifty years ago, and Champy et al.5, developed it five years later. By positioning a plate along the so called optimum line of bone fixation, the technique uses miniplate fixation to offset distracting pressures that arise along the fracture line during mandibular function. This line indicates that the plate might be positioned just below or along the mandibular oblique line in the mandibular angle region5. However, after fifty years of expertise and use, experimental and clinical research have demonstrated that miniplate fixation's appropriateness for repairing angle fractures is still debatable. For instance, Kroon et al.14, showed that loading pressures close to the fracture line caused only minor distraction of the mandibular inferior border. Placing a miniplate in the “ideal line” suggested by Champy et al.5, would not stop this distraction. Choi et al.15, shown in a related in vitro investigation that the addition of a second little plate along the inferior border aids in stabilizing fixation during functional loading.

Postoperative infection rates with multidrug-resistant bacteria are significant in Yemen, despite advancements in surgery both domestically and internationally16-22. Also, despite surgical advances, the mandibular fractures treatment is still linked with multiple complications and has high postoperative complication rates4,5,8. However, Levy et al.21, confirmed a low complication rate when treating mandibular fractures using two unicortical miniplates for internal fixation of angular fractures, compared to a higher complication rate when using a single miniplate, while Ellis and Walker8 suggested that using a single miniplate at the angular provides a lower complication rate than using two miniplates.

The current study's objectives were to: (1) assess our performance in situations where our institution employed two unicortical miniplates to treat mandibular angle fractures; and (2) compare our findings with those of other studies and reconstruction plates.

 

METHODS

 

The Department of Oral and Maxillofacial Surgery at the Military Hospital in Sana'a, Yemen, carried out the study between 2020 and 2024, diagnosing mandibular angle fractures in two equal groups. Reconstruction plates were used for 20 patients in Group A, and double miniplate fixation was used for another 20 patients in Group B. After that, postoperative complications were examined. Between weeks two and eight, each patient received a follow-up call. After surgery, the two groups were recorded and evaluated radiographically and clinically for plate exposure, plate stability, surgical site swelling, restricted mouth opening, hematoma, infection, malocclusion, and mandibular deviation.

Statistical Analysis: To statistically compare the clinical complication rates of the two methods (reconstruction plates VS double miniplate fixation), the Z-test was used for the two comparison rates in reconstruction plates and double miniplate fixation. The risk ratio (RR) was also calculated for each method and was a measure of the risk of postoperative clinical complications in Group A compared to the risk of the same event in Group B. risk ratios are used in prospective studies, such as cohort studies, and clinical trials such as ours. We also conducted descriptive analyses using frequency distribution, percentages, and proportions.

 

RESULTS

 

Table 1 shows the distribution of patients with mandibular angle fractures treated with reconstruction plates and compared with double miniplate fixation. The number of patients treated with reconstruction plates was 20, of whom 17 were male (85%) and 3 were female (15%). The double miniplate fixation group included 20 patients, all of whom were male. Table 2 shows the complication rates, mean differences, and statistical significance between patients with inferior lateral angle fractures treated with reconstruction plates compared to those treated with double miniplates. 

When plate exposure was considered as a complication, 15% of patients treated with reconstruction plates experienced bone exposure, while none occurred with double miniplates, representing a rate difference of 15%, a coefficient of variation (X2)=3.2, and a p-value of 0.07. 10% of patients treated with reconstruction plates encountered poor stability when Stability was taken into consideration as a complication, whereas 5% of patients treated with double miniplates experienced this. This represents a 5% rate difference, a coefficient of variation (X2)=0.32, and a p-value of 0.63. 30% of patients treated with reconstruction plates reported edema at the plate site, compared to 10% treated with double miniplates. This represents a 20% rate difference, a coefficient of variance (X2)=0.24, and a p-value of 0.11. 15% of patients treated with reconstruction plates reported nerve injury, compared to 10% who received twin miniplates.This represents a 5% rate difference, a coefficient of variation (X2)=0.22, and a p-value of 0.63 when nerve injury is taken into account as a consequence. Open Mouth Limitation was regarded as a problem, and it happened in 0% of patients treated with reconstruction plates and 0% of patients treated with double miniplates, indicating a 0% rate difference between the two techniques. 10% of patients treated with reconstruction plate’s encountered hematoma, whereas 0% experienced it with double miniplates. This represents a 10% rate difference, a coefficient of variation (X2)=0.2.1, and a p-value of 0.15 when hematoma was taken into account as a consequence. With a 10% rate difference, a coefficient of variation (X2)=1.1, and a p-value of 0.29, 15% of patients treated with reconstruction plates and 5% of patients treated with double miniplates suffered infection when infection at the site of surgery was taken into consideration as a consequence. Total 15% of patients treated with reconstruction plates suffered occlusion, compared to 0% with double miniplates, when occlusion was taken into account as a complication. This represents a 15% rate difference, a coefficient of variation (X2)=3.2, and a p-value of 0.07. 5% of patients treated with twin miniplates suffered Deviation Opening, compared to 10% of patients treated with reconstruction plates. This represents a 5% rate difference, a coefficient of variation (X2)=0.35, and a p-value of 0.55. In conclusion, the double miniplates approach had lower rates of problems than the reconstruction plate approach, indicating that the two miniplates approach is superior.Table 3 shows the risk ratio (RR), which measures the risk of postoperative complications in the reconstruction plate group compared to the risk of complications in the two-miniplate group. The RR for plate exposure was found to be 2.2 times higher when the reconstruction plate was used to treat mandibular angle fractures, with a range of 1.5–3.1, p < 0.05. This indicates an increased risk of these complications in the exposed group (reconstruction plate group). There was a significant RR for occlusion contracture of 2.7 times higher when the reconstruction plate was used to treat mandibular angle fractures, with a range of 1.5–3.7, p < 0.05. There was a significant RR for opening deviation contracture of 2.2 times higher when the reconstruction plate was used to treat angle fractures, with a range of 1.5–29, p<0.045. However, there is no significant association between the use of reconstruction plates for the treatment of angle fractures and the occurrence of complications such as instability, swelling, nerve injury, open mouth restriction, hematoma, and infection.

Table 4 shows the risk ratio (RR), which measures the risk of postoperative complications in the double-miniplate group compared with the reconstruction plate group. A significant protection rate was observed for double-miniplate against plate exposure complications (p=0.05), as well as a significant protection rate for double-miniplate against occlusion complications (p=0.05). However, double-miniplate fixation showed a low or complete absence of complications. This suggests that the use of double-miniplate fixation reduced the risk of these complications in the double-miniplate group.

 

DISCUSSION

 

Between 23 and 42 percent of all mandibular fractures are angle fractures1,9,10,23-25. The presence of a third molar and the angle's low cross-sectional bone area are partly responsible for its frequent involvement in mandibular fractures24,26,27. The location of fracture is also influenced by other factors, including bone mass and density, impact point, direction, and severity24. Since the fracture is often posterior to the dentition and the bone in the mandibular angle region is thin inferiorly, MMF cannot provide sufficient stability. The opposing muscular forces of the elevator group (masseter, medial and lateral pterygoids, and temporalis muscles) and the depressor group (geniohyoid, genioglossus, mylohyoid, and digastric muscles) frequently cause unstable rotation or distraction of the proximal and distal fracture segments. In addition, a third molar may reduce bone contact, hinder reduction, change the vascularity of the fracture site, or harbor pathogenic organisms28. In situations requiring the treatment of mandible fractures, maxillomandibular fixation may present a variety of possible issues, such as inadequate nutrition, temporomandibular joint disorders, oral airway impairment, patient discontent, noncompliance, and social difficulty7,29-31.

With a 10% rate difference, a coefficient of variation (X2)=1.1, and a p-value of 0.29, 15% of patients treated with reconstruction plates and 5% of patients treated with double miniplates experienced infection when surgical site infection was taken into account as an outcome in the current study. It is recognized that the use of rigid internal fixation may avoid some of the difficulties associated with MMF. Passeri et al.32, 1 conducted a retrospective review of complications in 96 patients, with 99 angle fractures, treated with either closed or non-rigid fixation with MMF. The researchers found an overall complication rate of 17%, with infection being the most common. James et al.33, also reviewed the non-rigid treatment of 253 patients; 136 fractures were through the angle. Nine angle injuries occurred, representing a 7% infection rate in this group.

Our results showed that the use of a dual miniplate fixation is superior to the reconstruction method. This is similar to the recommendations of Michelet et al.12, and Champy et al.5, for the use of a non-compression unicortical miniplate for mandibular fracture fixation. Based on the results of other biomechanical studies, Champy et al.5, described two lines of fixation located along the external oblique line and the superior buccal cortex. Since the work of Michelet et al.12, and Champy et al.5, non-compression miniplate fixation of angular fractures has gained popularity. Some of the advantages of monocortical miniplate fixation over other methods of rigid internal fixation (such as reconstruction or compression plates) include: (1) intraoral incisions are reduced or eliminate the need for a large external scar; (2) potential risks to the inferior alveolar nerve and marginal mandibular nerve are reduced; (3) simultaneous observation of a reduction in the fracture line and occlusal relationships is possible; (4) miniplates are easier to adapt to bony curvatures than compression plates or reconstruction; (5) The intraoral approach may be less technically demanding than the extraoral approach22,24.

In the current study, 15% of our patients treated with reconstruction plates developed malocclusion, compared to 0% of those treated with double miniplate fixation, when malocclusion was taken into account as a complication. Biomechanical analysis by Crone et al.15, showed that when occlusal load was applied to identical molars, flattening occurred along the lower edge of the angle in a single miniplate angle fracture model. This study, along with in vitro studies by Choi et al.15, and a clinical study by Levy et al.21, provided evidence that double miniplate fixation may provide better fixation of angle fractures compared to the Champey et al.5, method. Levy et al.21, reported on 32 angle fractures treated with a paired miniplate in which 1 complication (3.1%) occurred (infection) compared to 5 complications (26.3%) in 19 patients treated with a single miniplate across the oblique line (infection, n=3 [15.7%]; delayed union, n=1(5.3%); and malocclusion, n=1 [5.3%]).

Additionally, the infection rate in our study using the paired miniplates approach was 5%. This contrasts with the results of other studies, which revealed that Ellis and Walker8 used paired miniplates to get a high infection rate of 25% and an overall complication rate of 28%. Hardware had to be removed from 16 out of 69 fractures in order to prevent infection. Ellis and Walker8 hypothesized that the extraction of teeth in the line of fracture would contribute to the increased infection rate. Although other factors such as multidrug-resistant bacteria may also be involved and complicate cases as infected cases become difficult to treat with antibiotics35-38. Ellis and Walker39 assessed the outcomes of treating mandibular angle fractures with one non-compression miniplate in a different trial. All of our patients were treated with antibiotics and 0.1% chlorhexidine rinses from the time of presentation until approximately 7 to 10 days postoperatively. This therapeutic approach may have contributed to the low infection rates observed in our study. Furthermore, the duration of treatment did not affect the likelihood of infection or any other complications in this study. Proper use of antibiotics and proper oral hygiene may have improved infection outcomes and allowed for a longer delay in treatment, without adverse consequences. Other studies comparing our results did not report whether antibiotics were used similarly to our study.

The results of 113 patients with 121 angle fractures treated with neutral reconstruction plates, compression plates, or lag screw fixation were assessed in a research by Iizuka and Lindqvist40. In 8 patients (6.6%), a postoperative infection was found. The use of compression plates at the angle following tooth extraction at the fracture line was linked to infection, according to the authors40. High infection rates following internal fixation of the mandibular angle have been reported in a number of different studies, particularly in cases where a tooth has been removed from the fracture line42-44. However, according to Iizuka and Lindqvist40, malocclusion was more common when two distinct osteosyntheses were carried out as opposed to one osteosynthesis (26.2% vs. 8.5%).

Compared to 10% of patients treated with twin miniplates, 15% of patients treated with reconstruction plates in the current research suffered nerve damage. When considering nerve damage as a consequence, this results in a 5% rate difference, a coefficient of variation (X2)=0.22, and a p-value of 0.63. The manipulation at the fracture site during surgery most likely caused the sensory abnormalities that were discovered after the procedure. It is unlikely that monocortical screws will cause nerve damage. Furthermore, it is uncertain if the sensory problems observed here were temporary due to the short follow-up time in this group (mean of 7 weeks).

Limitation of the study

It is crucial to acknowledge a few of this study's shortcomings. It is a retrospective review, to start. The very little follow-up time and patient non-compliance further reduced the study's strength. 

 

CONCLUSIONS

 

In the treatment of mandibular angle fractures using reconstruction plates, compared with fixation using two miniplates, fixation using two miniplates is the most effective and reliable treatment strategy for mandibular angle fractures, with lower complication rates. Complications were minimal in our study, with an infection rate of 5%, comparable to or higher than the infection rate using the reconstruction plate technique (15%). Occlusal disturbances were associated with the reconstruction plate technique, while none were reported with miniplate fixation. 

 

ACKNOWLEDGEMENT

 

Authors are thankful for the Sana’a University, Republic of Yemen to provide necessary facility for this work. 

 

AUTHOR’S CONTRIBUTIONS 

 

Awad MMA: Formal analysis, conceptualization, data organization, and clinical examinations. Al-Moyed KA: Editing. Al-Rahbi LM: review, supervision. Al-Ashwal AA:  review, supervision. Al-Shamahy HA: review, supervision. Final manuscript was checked and approved by all authors.  

 

DATA AVAILABILITY

 

Data will be made available on request.

 

CONFLICT OF INTEREST 

 

There are no conflicts of interest in regard to this project.

 

REFERENCES

 

  1. Al-Moraissi EA, Ellis E. Surgical management of anterior mandibular fractures: A systematic review and meta-analysis. J Oral Maxillofac Surg. 2014 Dec;72(12):2507.e1-11. https://doi.org/10.1016/j.joms.2014.07.042
  2. Dodson TB, Perrott DH, Kaban LB. Fixation of mandibular fractures: A comparative analysis of rigid internal fixation and standard fixation techniques. J Oral Maxillofac Surg 1990 Apr;48(4):362-6. PMID: 2313443. https://doi.org/10.1016/0278-2391(90)90431-z
  1. Ellis E 3rd. Treatment of mandibular angle fractures using the AO reconstruction plate. J Oral Maxillofac Surg. 1993 Mar;51(3):250-4; discussion 255. PMID: 8445465 https://doi.org/10.1016/s0278-2391(10)80166-1  
  1. Ellis E 3rd, Walker L. Treatment of mandibular angle fractures using two noncompression miniplates. J Oral Maxillofac Surg. 1994 Oct;52(10):1032-6; discussion 1036-7. https://doi.org/10.1016/0278-2391(94)90169-4  
  2. Champy M, Loddé JP, Schmitt R. Mandibular osteosynthesis by miniature screwed plates via a buccal approach. J Maxillofac Surg 1978 Feb;6(1):14-21. https://doi.org/10.1016/s0301-0503(78)80062-9. Niederdellmann H, Shetty V. Solitary lag screw osteosynthesis in the treatment of fractures of the angle of the mandible: A retrospective study. Plast Reconstr Surg. 1987 Jul;80(1):68-74. PMID: 3602161. https://doi.org/10.1097/00006534-198707000-00010  
  1. Cawood JI. Small plate osteosynthesis of mandibular fractures. Br J Oral Maxillofac Surg. 1985 Apr;23(2):77-91.https://doi.org/10.1016/0266-4356(85)90057-9  
  1. Theriot BA, Van Sickels JE, Triplett RG. Intraosseous wire fixation versus rigid osseous fixation of mandibular fractures: A preliminary report. J Oral Maxillofac Surg. 1987 Jul;45(7):577-82. PMID: 3474374. https://doi.org/10.1016/0278-2391(87)90267-9  
  1. Ellis E 3rd, Walker L. Treatment of mandibular angle fractures using two noncompression miniplates. J Oral Maxillofac Surg. 1994 Oct;52(10):1032-6; discussion 1036-7. https://doi.org/10.1016/0278-2391(94)90169-4  
  2. Sharaf Aldeen HMA, Al-Rahbi LM, Al-Ashwal AA. Analysis of hardware removal in maxillofacial trauma: A retrospective study in a military hospital in Sana’a, Yemen. Universal J Pharm Res 2024; 8(6):46-51. https://doi.org/10.22270/ujpr.v8i6.1039
  1. Al-Rahbi LM, MAMF Gamel, Al-Shamahy HA. Treatment of comminuted mandibular fracture with closed reduction and mandibular fixation versus open reduction and internal fixation.Universal J Pharm Res 2024; 9(5): 1-8. https://doi.org/10.22270/ujpr.v9i5.1192
  2. Al-Rahbi LM, Mohammed Setten HH, Al-Shamahy HA. Impact of 3D printing in reconstruction of maxillofacial bone defects experimental study in a military hospital in Sana’a city, Yemen. Universal J Pharm Res 2025;10(1):1-8.https://doi.org/10.22270/ujpr.v10i1.1271
  3. Prein J, Kellman RM. Rigid internal fixation of mandibular fractures--basics of AO technique. Otolaryngol Clin North Am. 1987 Aug;20(3):441-56. [PMID: 3684289]
  4. Michelet FX, Deymes J, Dessus B. Osteosynthesis with miniaturized screwed plates in maxillo-facial surgery. J Maxillofac Surg. 1973 Jun;1(2):79-84. PMID: 4520558 https://doi.org/10.1016/s0301-0503(73)80017-7  
  1. Kroon FH, Mathisson M, Cordey JR. The use of miniplates in mandibular fractures. An in vitro study. J Craniomaxillofac Surg. 1991 Jul;19(5):199-204. PMID: 1894737. https://doi.org/10.1016/s1010-5182(05)80547-5.
  2. Choi BH, Yoo JH, Kim KN. Stability testing of a two miniplate fixation technique for mandibular angle fractures. An in vitro study. J Craniomaxillofac Surg. 1995 Apr;23(2):123-5. PMID: 7790506. https://doi.org/10.1016/s1010-5182(05)80460-3  
  1. Al-Yosaffi EA, Al-Shamahy HA, Othman AO. Antibiotic sensitivity of bacterial bloodstream infections in the intensive care unit patients of university hospitals in Sana’a city, Yemen. Universal J Pharm Res 2023; 8 (5): 1-8. https://doi.org/10.22270/ujpr.v8i5.1004
  2. Alhadi, YAA, Al-Kibsi TA, Al-Shamahy HA. Surgical site infections: Prevalence, associated factors and antimicrobial susceptibility patterns of the bacterial isolates among postoperative patients in Sana’a, Yemen. Universal J Pharm Res 2022; 7(3):1-8. https://doi.org/10.22270/ujpr.v7i3.777
  3. Al-Haifi AY, Al Makdad ASM, Salah MK. Urinary tract infections in post operative patients: Prevalence rate, bacterial profile, antibiotic sensitivity and specific risk factors. Universal J Pharm Res 2020; 5(3):1-8. https://doi.org/10.22270/ujpr.v5i3.411
  1. Al-Shehari MM, Al-Khamesy KSA, Al-Moyed KA. Distribution and antibacterial resistance of wound pathogenic bacteria in patients of Sana’a hospitals, Yemen. Universal J Pharm Res 2023; 8(3):1-8.  https://doi.org/10.22270/ujpr.v8i3.942
  1. Al-Akwa AAY, Zabara A, Al-Shamahy HA. Prevalence of staphylococcus aureus in dental infections and the occurrence of MRSA in isolates. Universal J Pharm Res 2020; 5(2):1-8. https://doi.org/10.22270/ujpr.v5i2.384
  2. Al-Hamzi MA, Sharafuddin AH, Al-Shameri BA. The effect of dental implants on aerobic bacteria colonization in the oral cavity and the antibiotic profile of common isolated aerobic bacteria. Universal J Pharm Res 2023; 8(4):1-8. https://doi.org/10.22270/ujpr.v8i4.969
  3. Levy FE, Smith RW, Odland RM. Monocortical miniplate fixation of mandibular angle fractures. Arch Otolaryngol Head Neck Surg 1991 Feb;117(2):149-54. PMID: 1991053 https://doi.org/10.1001/archotol.1991.01870140037002
  1. Schierle HP, Schmelzeisen R, Rahn B. One- or two-plate fixation of mandibular angle fractures? J Craniomaxillofac Surg. 1997 Jun;25(3):162-8. PMID: 9234097 https://doi.org/10.1016/s1010-5182(97)80009-1.
  1. Safdar N, Meechan JG. Relationship between fractures of the mandibular angle and the presence and state of eruption of the lower third molar. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995 Jun;79(6):680-4. PMID: 7621022 https://doi.org/10.1016/s1079-2104(05)80299-9.
  1. Pape HD, Herzog M, Gerlach KC. The change in mandibular fracture treatment from 1950 to 1980 using the example of the cologne clinic. German Dentist Z 1983; 38:301.
  2. Mathog RH, Boies LR. Nonunion of the mandible. Laryngoscope. 1976;86:908-920.
  3. Lee JT, Dodson TB. The effect of mandibular third molar presence and position on the risk of an angle fracture. J Oral Maxillofac Surg. 2000 Apr;58(4):394-8; discussion 399. PMID: 10759119. https://doi.org/10.1016/s0278-2391(00)90921-2  
  1. Assael LA. Treatment of mandibular angle fractures: Plate and screw fixation. J Oral Maxillofac Surg 1994 Jul;52(7):757-61. PMID: 8006742  https://doi.org/10.1016/0278-2391(94)90495-2
  1. Wald RM, Abemayor E, Zemplenyi J. The transoral treatment of mandibular fractures using noncompression miniplates: A prospective study. Ann Plast Surg 1988;20:409-413.
  2. Strelzow VV, Strelzow AG. Osteosynthesis of mandibular fractures in the angle region. Arch Otolaryngol 1983 Jun;109(6):403-6. PMID: 6847500. https://doi.org/10.1001/archotol.1983.00800200049013
  1. Schmelzeisen R, McIff T, Rahn B. Further development of titanium miniplate fixation for mandibular fractures: Experience gained and questions raised from a prospective clinical pilot study with 2.0 mm fixation plates. J Craniomaxillofac Surg 1992;20:251-256.
  2. Passeri LA, Ellis E 3rd, Sinn DP. Complications of nonrigid fixation of mandibular angle fractures. J Oral Maxillofac Surg 1993 Apr;51(4):382-4. PMID: 8450355 https://doi.org/10.1016/s0278-2391(10)80350-7  
  1. Fedok FG, Van Kooten DW, DeJoseph LM. Plating techniques and plate orientation in repair of mandibular angle fractures: An in-vitro Laryngoscope 1998 Aug;108(8 Pt 1):1218-24. PMID: 9707247. https://doi.org/10.1097/00005537-199808000-00022
  1. James RB, Fredrickson C, Kent JN. Prospective study of mandibular fractures. J Oral Surg. 1981;39:275-281.
  2. Edwards TJ, David DJ. A comparative study of miniplates used in the treatment of mandibular fractures. Plast Reconstr Surg. 1996 May; 97(6):1150-7. https://doi.org/10.1097/00006534-199605000-00009 PMID: 8628797
  3. Al-Tahish GAA, Measar MAH, Al-Safani Antimicrobial resistance patterns among bacterial pathogens isolated from clinical samples in Sana’a hospitals. Universal J Pharm Res 2024; 9(3):1-8. https://doi.org/10.22270/ujpr.v9i3.1112
  1. Alshamahi EYA, Al-Shamahy HA, Musawa Bacterial causes and antimicrobial sensitivity pattern of external ocular infections in selected ophthalmology clinics in Sana’a city”. Universal J Pharm Res 2020; 5(3):1-8. https://doi.org/10.22270/ujpr.v5i3.409
  2. Abbas AKM, Al-Kibsi TAM, Al-Akwa Characterization and antibiotic sensitivity of bacteria in orofacial abscesses of odontogenic origin. Universal J Pharm Res 2021; 5(6):1-8. https://doi.org/10.22270/ujpr.v5i6.510
  1. Al-Mehdar AA, Al-Akydy AG. Pattern of antimicrobial prescribing among in-patients of a teaching hospital in yemen: A prospective study. Universal J Pharm Res 2017; 2 (5):1-8. https://doi.org/10.22270/ujpr.v2i5.R3
  2. Ellis E 3rd, Walker LR. Treatment of mandibular angle fractures using one noncompression miniplate. J Oral Maxillofac Surg. 1996 Jul;54(7):864-71; discussion 871-2. PMID: 8676232 https://doi.org/10.1016/s0278-2391(96)90538-8  
  1. Iizuka T, Lindqvist C. Rigid internal fixation of fractures in the angular region of the mandible: An analysis of factors contributing to different complications. Plast Reconstr Surg. 1993 Feb;91(2):265-71; discussion 272-3. PMID: 8430140
  2. Iizuka T, Lindqvist C, Hallikainen D. Infection after rigid internal fixation of mandibular fractures. J Oral Maxillofac Surg. 1991;49:585-593.
  3. Ikemura K, Hidaka H, Etoh T. Osteosynthesis in facial bone fractures using miniplates. J Oral Maxillofac Surg. 1988;46:10-14.
  4. Anderson T, Alpert B. Experience with rigid fixation of mandibular fractures and immediate function. J Oral Maxillofac Surg. 1992 Jun;50(6):555-60; discussion 560-1. PMID: 1593314 https://doi.org/10.1016/0278-2391(92)90432-y  
  1. Yazdani J, Taheri Talesh K, Kalantar Motamedi MH. Mandibular Angle Fractures: Comparison of one miniplate vs. two miniplates. Trauma Mon 2013 Spring;18(1):17-20. https://doi.org/10.5812/traumamon.9865