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With an ageing population, oral and maxillofacial surgeons are seeing an increasing number of fractures of the edentulous mandible. Management of such fractures still evokes much debate and no single technique has been universally accepted. Whatever the approach, they are notoriously difficult to manage intraoperatively mainly because of the difficultly in maintaining reduction and angulation of both fractures during fixation and adaptation of the plate, which increases the total anaesthetic time. In general, elderly patients are more sensitive to anaesthetic agents because of a progressive loss of functional reserve in all organ systems. Therefore, an important objective for perioperative care is to reduce the level of stress and avoid testing of the limited physiological reserve.
We present our technique for the management of bilateral fractures of the edentulous mandibular body (so-called “bucket handle” fractures) with a pre-contoured 2.4 mm locking reconstruction plate through an extraoral approach. For each patient we produced a stereolithographic model in house, which was used to reduce the fractures in the laboratory and to customise the contour of the plate used for reconstruction (Fig. 1). It is essential to mark the plate at the site of the reduced fracture to ensure that it is correctly positioned and crucially, that it guides the reduction and angulation of the fracture (Fig. 2).
Fig. 2A 2.4 mm reconstruction plate contoured to the mandible. The black line on the plate is the fracture line, which is used intraoperatively to orientate the plate precisely at the fracture site.
This technique has minimised the total anaesthetic time (less than 50 minutes/patient in our series), and use of the customised plate has enabled us to achieve a quick, accurate, and correctly angulated open reduction and internal fixation (Fig. 3). It has avoided the problem of reducing one aspect of the bucket handle while distracting and changing the angulation of the other, a complication often encountered in this fracture pattern.
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