Systematic Review

Trauma

Int. J. Oral Maxillofac. Surg. 2018; 47: 330–338
http://dx.doi.org/10.1016/j.ijom.2017.08.009, available online at http://www.sciencedirect.com
Three-dimensional strut plate
for the treatment of mandibular
fractures: a systematic review
J. C. S. de Oliveira, L. B. Moura, J. D. S. de Menezes, M. A. C. Gabrielli, V. A. Pereira
Filho, E. Hochuli-Vieira: Three-dimensional strut plate for the treatment of
mandibular fractures: a systematic review. Int. J. Oral Maxillofac. Surg. 2018; 47:
330–338. ã 2017 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

Abstract. The treatment of mandibular fractures by open reduction and internal
fixation is very variable. Thus, there are many controversies about the best fixation
system in terms of stability, functional recovery, and postoperative complications.
This systematic review sought scientific evidence regarding the best indication for
the use of three-dimensional (3D) plates in the treatment of mandibular fractures. A
systematic search of the PubMed/MEDLINE, Elsevier/Scopus, and Cochrane
Library databases was conducted to include articles published up until November
2016. Following the application of the inclusion criteria, 25 scientific articles were
selected for detailed analysis. These studies included a total of 1036 patients (mean
age 29 years), with a higher prevalence of males. The anatomical location most
involved was the mandibular angle. The success rate of 3D plates was high at this
location compared to other methods of fixation. In conclusion, the use of 3D plates
for the treatment of mandibular fractures is recommended, since they result in little
or no displacement between bone fragments.
0901-5027/030330 + 09 ã 2017 International Association of Oral and Maxillofacial Surge
J. C. S. de Oliveira1, L. B. Moura2,
J. D. S. de Menezes2,
M. A. C. Gabrielli2,
V. A. Pereira Filho2,
E. Hochuli-Vieira2

1Oral and Maxillofacial Surgery Residency
Program, Department of Diagnosis and
Surgery, Dental School at Araraquara,
UNESP – Universidade Estadual Paulista,
Araraquara, São Paulo, Brazil; 2Department
of Diagnosis and Surgery, Dental School at
Araraquara, UNESP – Universidade Estadual
Paulista, Araraquara, São Paulo, Brazil
Key words: mandible fracture; miniplate osteo-
synthesis; grid plate; 3D miniplate; internal rigid
fixation; standard miniplate.

Accepted for publication 30 August 2017
Available online 18 September 2017
Mandibular fractures are frequent in facial
trauma and represent between 35.54%1

and 44.2%2 of all facial fractures. This
high incidence is a result of the mandibu-
lar anatomy and characteristics. The man-
dibular bone includes fragile areas due to
the presence of third molars in the man-
dibular angle and bone narrowing in the
subcondylar region. It constitutes the low-
er third of the face, and possesses certain
mobility due to the presence of the tempo-
romandibular joints. These fractures result
in functional problems (speech, chewing,
and swallowing), as well as social pro-
blems due to aesthetic discrepancies3. The
ideal treatment for mandibular fractures
should aim at a perfect anatomical reduc-
tion, stable fixation, and satisfactory future
function of the mandible with the least
possible repercussions for the joints4.
Rigid internal fixation (RIF) was ini-

tially used in the oral and maxillofacial
area in the late 1970s5, and since the work
of Michelet et al.6 and Champy et al.7,
osteosynthesis using miniplates has be-
come an indispensable method of fixation
in maxillofacial surgery5. Techniques of
open reduction for mandibular fractures
have changed and diversified greatly in
recent decades3,8, however there is still no
consensus regarding the best method of
treatment9,10. These methods include the
use of lag screws11, reconstruction
Plates12, dynamic compression Plates13,
miniplates14,15, locking Plates14, and
three-dimensional (3D) Plates16,17.
ons. Published by Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ijom.2017.08.009
http://dx.doi.org/10.1016/j.ijom.2017.08.009


Mandibular fractures treated by 3D strut plate 331

Fig. 1. Flowchart of the systematic review process.
Issues related to the stability provided
by the various fixation systems, especially
in mandibular angle fractures, have be-
come a key point of debate among sur-
geons4. Therefore, it is prudent to consider
the factors that may justify the use of one
type of fixation over another, such as the
patient’s age, the location and level of the
fracture line, degree of displacement, se-
verity of mandibular involvement, degree
of alteration in occlusion, and the experi-
ence of the surgeon, as well as to inform
the patients about the possible advantages
and disadvantages of the treatment alter-
natives18.
Among the fixation systems and tech-

niques, the use of 3D plates for the treat-
ment of mandibular fractures is relatively
new, introduced by Farmand in
19923,5,19,20. The basic concept of the
3D system is the use of a geometrically
closed quadrangular or rectangular plate
fixed with screws to provide stability in
the three dimensions10,21. The principle of
this fixation is supported by the idea that
the devices are not positioned in the tra-
jectory lines of compression and tension
forces, but in the weaker structure
lines21,22.
The objective of this study was to per-

form a systematic review of the literature
on the treatment of mandibular fractures
with 3D plates, in order to answer the
following question: What is the scientific
evidence regarding the indication for this
technique?

Materials and methods

This systematic review was performed
according to the PRISMA statement (Pre-
ferred Reporting Items for Systematic
Reviews and Meta-Analyses)23 and the
Cochrane Handbook for Systematic
Reviews of Interventions24.

Search strategy and selection criteria

The initial bibliographic research was per-
formed in the MEDLINE (via PubMed),
Elsevier (via Scopus), and Cochrane Li-
brary databases, using four lines of search
elements: (1) ‘‘grid plate’’ AND ‘‘man-
dibular fracture’’; (2) ‘‘3d plate’’ AND
‘‘mandibular fracture’’; (3) ‘‘3 dimen-
sional plate’’ AND ‘‘mandibular frac-
ture’’; (4) ‘‘strut plate’’ AND
‘‘mandibular fracture’’.
For the initial selection, three indepen-

dent reviewers (JCSO, JSDM, and LBM)
reviewed the title and/or abstract of the
articles against established inclusion cri-
teria: studies performed in human beings;
specific studies on the use of 3D plates for
the treatment of mandibular fractures;
published in the English language; type
of study: case series and retrospective and
prospective clinical trials. There was no
restriction on date of publication.
After the initial selection, the three

examiners reviewed the full texts of the
selected articles and identified those for
inclusion in the final review using the
same eligibility criteria.

Data extraction

The examiners independently extracted
the data from the articles included in the
final review. The data extracted were the
type of study, number of patients and
fractures, location and displacement of
the fracture, surgical approach, type of
3D plate used, complications, and success
rate (%). In order to standardize the suc-
cess rate of the studies, the cases in which
re-operation was required for the removal
of fixation material, there was bad union or
non-union, fixation failure, or an unsatis-
factory postoperative condition, such as
inadequate occlusion, as well as those in
which there was a need for maxilloman-
dibular fixation (MMF) or there was oc-
clusal wear, were considered as failures.
Discrepancies in data extraction between
the reviewers were resolved by further
discussion. Data were analyzed using de-
scriptive statistics.

Quality assessment

The evaluation of methodological quality
was performed using the PRISMA state-
ment criteria23, in order to verify the
strength of the available scientific evi-
dence in the current literature for use in
clinical decision-making. The classifica-
tion of potential risk of bias in each study
followed pre-established criteria used in
previous reviews25: random selection in
the population (sample); definition of in-
clusion/exclusion criteria; report of patient
loss to follow-up; validated measure-
ments; statistical analysis.
Studies that presented all of the above

criteria were classified as having a low risk
of bias, those that lacked one criterion
were classified as having a moderate risk
of bias, and those that lacked two or more
criteria were classified as having a high
risk of bias.

Results

The electronic search was conducted in
November 2016 and identified 281 arti-
cles. Eighty-two were determined to be
relevant after reading the title and/or ab-
stract. After removing duplicates, the
complete texts of 27 articles were evalu-
ated against the previously established
criteria. Two of these articles did not meet
the inclusion criteria and were excluded
from the study. The final review included
25 articles. The year of publication of the
articles selected ranged from 2005 to
2016. Figure 1shows the flowchart of
the article selection process.
Among the articles selected for the final

review, 16 reported prospective studies3–
5,9,10,18,21,22,26–33, seven reported retro-
spective studies8,17,34–38, and two reported



332 de Oliveira et al.
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case series16,39. Regarding the evaluation
of quality, three studies presented a low
risk of bias10,31,32, six a moderate risk3–
5,17,21,30, and 16 a high risk8,9,16,18,22,26–
29,33–39 (Table 1). Moreover, 11 studies
exclusively concerned mandibular frac-
tures treated using 3D plates (Table
2)8,9,16,26–29,34–36,39, and 14 studies com-
pared 3D plates with other treatment
methods, mainly a 2.0-mm fixation plate
system (Table 3)3–5,10,17,18,21,22,30–33,37,38.
The studies included a total of 1036

patients, with 3D plates being used in
816 patients. The mean age of patients
enrolled in the studies was 29 years, and
no study included children. Regarding the
sex distribution, there was a higher preva-
lence of male subjects in the studies that
specified sex (647 male, 91 female); some
studies did not specify the data for
sex18,29,32,34.
The main causes of the mandibular

fractures were traffic accidents, assaults,
and interpersonal violence. For the 841
fractures treated with 3D plates, the most
commonly involved anatomical site was
the angle region, with 666 fractures, fol-
lowed by 52 condyle fractures (subcondy-
lar region), 18 fractures in the anterior
region (symphysis and parasymphysis),
and 2 body fractures5,32.
Regarding the descriptive studies using

3D plates (Table 2), of those fractures with
a reported level of displacement (n = 349),
131 showed no displacement and 184
showed mild displacement9,28,34–36. The
intraoral approach was the method of
choice for the treatment of 555 mandibular
angle fractures; 34 mandibular angle frac-
tures were treated via extraoral/facial ap-
proach, without damage to the facial
nerve. Regarding cases of failure, the fix-
ation devices had to be removed in 31
cases, due to infection, non-union, or plate
fracture.
In the comparative studies between 3D

plates and other fixation methods (Table
3), three of the 25 studies included
reported a higher rate of postoperative
complications in fractures treated with
3D plates, regardless of the fracture loca-
tion10,22,32.
The lowest success rate of 3D plates

was found for the anterior region of the
mandible, with a success rate of 77.8%,
while the success rate in the angle region
was 78.2%. The main complications ob-
served were inferior alveolar nerve dis-
orders and failure/necessity for removal
of the fixation material (Table 4). Regard-
ing the cases treated with conventional
fixation systems, the main complication
was the need for postoperative MMF
(Table 5).



M
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Table 2. Descriptive analysis of studies using three-dimensional plates included in the review.

Year Author Type of study Number of patients/fractures Type of plate Classification of fracture Surgical access Complications Success (%)

2016 Sawatari et al.34 Retrospective 222/222 3D rectangular 222 angle fracture:
129 no displacement
78 moderate displacement
15 severe displacement

Intraoral 19 IAN impairment
15 fixation removal
10 dehiscence
10 infection
9 trismus
3 malocclusion

91.8

2016 Pandey et al.26 Prospective 15/15 3D grid 15 angle fracture:
14 with displacement
1 no displacement

Intraoral 5 dehiscence 100.0

2015 Chaudhary et al.27 Prospective 15/15 Trapezoidal condylar 15 subcondylar fracture Facial No complications 100.0
2014 Balakrishnan et al.39 Case series 6/12 3D plate:

10 quadrangular
2 rectangular

7 parasymphysis fracture
3 subcondylar fracture
2 angle fracture

NR NR 100.0

2014 Chhabaria et al.28 Prospective 20/21 3D strut grid 21 angle fracture:
16 severe displacement
5 mild displacement

19 Facial
(retromandibular)
2 Intraoral

3 IAN impairment
(temporary)
2 infection

100.0

2013 Prasad et al.29 Prospective 18/20 3D grid 9 parasymphysis fracture
7 angle fracture
2 symphysis fracture
2 body fracture

Intraoral 3 infection 2 IAN impairment
2 inadequate occlusion

90.0

2013 Wolfswinkel et al.8 Retrospective 34/36 3D rectangular 36 angle fracture Intraoral 3 infection with fixation removal
1 re-operated for non-union

88.9

2011 Hochuli-Vieira et al.16 Case series 45/45 3D rectangular 45 angle fracture
Displacement <1 cm

Intraoral 4 fixation
unsatisfactory
2 mobility
2 infection
1 inadequate reduction

88.9

2009 Bui et al.35 Retrospective 49/49 3D strut rectangular 49 angle fracture:
Mild displacement

Intraoral 4 infection 100.0

2007 Zix et al.9 Prospective 20/20 3D straight,
3D strut

20 angle fracture:
16 mild displacement
2 moderate displacement
2 severe displacement

Intraoral 2 dehiscence
2 IAN impairment
1 fixation fracture

95.0

2005 Guimond et al.36 Retrospective 37/37 3D strut
rectangular

37 angle fracture:
2 no displacement
17 mild displacement
17 moderate displacement
1 severe displacement

Intraoral 2 infection
1 dehiscence

100.0

3D, three-dimensional; IAN, inferior alveolar nerve; NR, not reported in the article.



3
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Table 3. Descriptive analysis of studies comparing three-dimensional plates and other methods of fixation.

Year Author
Type of
study

Number of
patients/fractures Type of plate Classification of fracture Surgical access Complications Success (%)

2016 Kanubaddy et al.30 Prospective 30/30 G1, n = 15
3D strut rectangular
G2, n = 15
One Plate 2.0 mm

30 angle fracture Facial
(submandibular)

G1: no complications
G2: 1 infection

G1: 100.0
G2: 100.0

2015 Al-Moraissi et al.31 Prospective 20/20 G1, n = 10
3D strut grid
G2, n = 10
One Plate 2.0 mm

20 angle fracture:
Linear
Displacement <1 cm

Intraoral G1: 1 infection, 2 palpable plates
G2: 1 infection, 1 failure,
1 dehiscence

G1: 100.0
G2: 90.0

2015 Sikora et al.18 Prospective 38/38 G1, n = 34
3D plate: 28 delta,
6 trapezoidal
G2, n = 4
One Plate 2.0 mm

38 condyle fracture:
32 lateral displacement
6 medial displacement

Facial
(transparotid)

G1: 1 screw loss
G2: 2 failure, 3 screw loss

G1: 97.0
G2: 50.0

2014 Sehgal et al.3 Prospective 30/53 G1, n = 25
3D grid
G2, n = 28
Two Plates 2.0 mm

16 parasymphysis fracture
3 symphysis fracture
11 body fracture
10 condyle fracture
(+3 treated conservatively)
10 angle fracture
G1:a

10 severe displacement
5 moderate displacement

G2:a

8 severe displacement
7 moderate displacement

NR G1: 1 dehiscence
G2: no complications

G1: 100.0
G2: 100.0

2013 Moore et al.37 Retrospective 104/106 G1, n = 73
3D strut grid
G2, n = 33
Champy

106 angle fracture Intraoral G1: 6 fixation removal
G2: 6 fixation removal

G1: 91.8
G2: 81.8

2013 Guy et al.17 Retrospective 90/90 G1, n = 68
3D strut grid
G2, n = 22
Champy, two Plates
2.0 mm, reconstruction
plate, MMF

90 angle fracture NR G1:7 re-operated, 6 IAN impairment,
4 dehiscence, 4 non/bad union, 3
infection, 2 malocclusion, 1 failure
G2: 3 re-operated, 3 IAN impairment, 2
infection, 2 dehiscence, 2 bad union, 2
malocclusion, 1 failure

G1: 79.4
G2: 63.6

2013 Vineeth et al.4 Prospective 20/20 G1, n = 10
3D grid
G2, n = 10
Champy

20 angle fracture:
20 unfavourable
4 severe displacement

Intraoral G1: 2 IAN impairment, 1 postop. MMF
G2: 3 postop. MMF, 2 infection, 1
fixation removal, 1 IAN impairment

G1: 90.0
G2: 60.0

2013 Xue et al.10 Prospective 13/13 G1, n = 6
3D grid
G2, n = 7
Champy

13 angle fracture Intraoral G1: 1 fixation removal, 1 dehiscence
G2: 1 fixation removal, 1 fixation
palpable

G1: 83.3
G2: 85.7



Mandibular fractures treated by 3D strut plate 335

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.

Discussion

There are many options for the treatment
of mandibular fractures by open reduction
and internal fixation, depending mainly on
the location and degree of displacement of
the fractures. These factors may affect the
surgeon’s decision, and as demonstrated
by this systematic review, there is no
consensus on the indication and predict-
ability of the outcome in relation to the use
of 3D plates for mandibular fractures.
3D plates are so named due to their

action in maintaining the fractured frag-
ments such that they are rigidly resistant to
forces in three dimensions, i.e. shear,
bending, and twisting forces19,31. Another
possible advantage of 3D plates described
in the literature is their ease of handling
and application at the surgical site9,35,
requiring less intraoperative time. Howev-
er, this was not confirmed by the present
review, and there was no statistically sig-
nificant difference in the comparative
studies that evaluated the operative
time5,10,17,22,30–33,38. Furthermore, in a
study by Xue et al., the average surgical
time using 3D plates was longer than that
for the Champy technique in mandibular
angle fractures10.
In this review, it was not possible to

verify the fracture pattern in all studies, so
it was not possible to correlate the degree
of displacement with the efficacy of the
fixation system. However, from the data
collected, a strong tendency towards the
use of 3D plates in fractures with little or
no displacement, regardless of their loca-
tion, and with good result predictability,
was observed. Nevertheless, in cases of
mandibular angle fracture, these devices
should be used with care, as demonstrated
in some studies4,9,34.
Cases of infection not related to fixation

failure/removal were not included, as this
complication does not represent the failure
of treatment and could be related to the
surgical approach, dehiscence, and post-
operative care. The presence of teeth in the
fracture line could not be accounted for
and evaluated, since most of the articles
did not report the number of teeth removed
during the operation. The decision to re-
move or maintain teeth in the fracture line
is based on variables such as tooth and
alveolar bone condition, clinical situation,
time, and type of treatment40. When the
surgical techniques and protocols recom-
mended in the literature are observed, the
possibility of infection as an eventual
postoperative complication is reduced41.
Among the descriptive studies, the low-

est success rate was 88.9%. This rate was
observed in two studies, one retrospective



336 de Oliveira et al.

Table 4. Description of treatment in 816 patients treated by means of three-dimensional plates.

Characteristics
Fracture

Angle Condyle Body Symphysis/parasymphysis Not specified Total

Fractures (n) 666 52 2 18 103a 841
Displacement

Present 322 – – 18 – 337 [340]
Severe 34 – – – 10 44
Moderate 142 – – – – 147 [142]
Small 146 – – – – 146
Absent 132 – – – – 132

Surgical access
Intraoral 555 – – 18 80 655 [653]
Facial 34 49 – – – 83

Complications
IAN impairment 32 – – – 4 36
Fixation failure/removal 31 – – – 5 36
Infection 27 – – – 5 32
Dehiscence 23 – – – 1 24
Trismus 9 – – – – 9
Inadequate occlusion 5 – – 4 1 10
Re-operated 8 – – – – 8
Non-union 5 – – – – 5
Mobility 2 – – – – 2
Inadequate reduction 1 – – – 1 2
Palpable plate 1 – – – – 1
Screw loss – 1 – – – 1
Postoperative MMF 1 – – – 8 9
Total complications 145 1 – 4 25 175

Success
Success (n) 521 52 [51] 2 14 76 [78] 666
Success rate (%) 78.2 100.0 [98.1] 100.00 77.8 73.8 [75.7] 79.2

IAN, inferior alveolar nerve; MMF, maxillomandibular fixation.
a Articles did not correlate fracture site with treatment.

Table 5. Description of treatment in 220 patients treated by conventional means.

Characteristics
Fracture

Angle Condyle Symphysis/parasymphysis Not specified Total

Fractures (n) 127 4 – 111a 242
Displacement

Present 10 4 – 15 29
Severe – – – 8 8
Moderate – – – 7 7
Small – – – – –
Absent – – – – –

Surgical access
Intraoral 90 – 20 58 168 [148]
Facial 15 4 – – 19

Complications
IAN impairment 4 – – 5 9
Fixation failure/removal 12 2 – 1 15
Infection 9 – – 5 14
Dehiscence 6 – 1 – 7
Trismus – – – – –
Inadequate occlusion 2 – 3 3 8 [5]
Re-operated 3 – – – 3
Non-union 2 – – – 2
Mobility – – 3 – 3 [-]
Inadequate reduction – – – – –
Palpable plate 1 – – – 1
Screw loss – 3 – – 3
Postoperative MMF 3 – – 17 20
Total complications 42 5 7 31 85 [78]

Success
Characteristics Success (n) 97 2 17 60 176 [159]

Success rate (%) 76.4 50.0 85.0 69.8 [54.1] 74.3 [65.7]

IAN, inferior alveolar nerve; MMF, maxillomandibular fixation.
a Articles did not correlate fracture site with treatment.



Mandibular fractures treated by 3D strut plate 337
study8 and one case series study16, both
evaluating the use of 3D plates in mandib-
ular angle fractures. In these studies, five
cases of infection were verified, with fixa-
tion material removal in three of them.
Furthermore there was the removal of
fixation material that was unsatisfactory,
an inadequate reduction of the fracture,
and a re-operation due to non-union, as
well as two cases of mandibular mobility.
Some authors argue that fracture mobility
is a causal factor for postoperative infec-
tions, which may have a decreased inci-
dence with improved fracture stabilization
with more stable devices9. However, Ellis
has stated that there is an inverse relation-
ship between fixation rigidity and the in-
cidence of complications15.
Regarding the comparative studies, the

3D plates showed better performance in
comparison to the alternative methods of
fixation (a 2.0-mm plate, 2 � 2.0 mm
plates, reconstruction plate, or MMF),
most probably due to the stability gained
in the three directions42 and resistance to
torque and malleability35,39. The success
rate with the use of 3D plates was greater
than 80% except in three comparative
studies5,17,22.
Some studies have reported that the use

of 3D plates results in minimal damage to
the inferior alveolar nerve (IAN)17,35.
Nevertheless this is not always the case:
of the three studies in which IAN im-
pairment was detected postoperative-
ly4,5,17, two presented a greater number
of patients with sensory alterations treated
with 3D Plates4,17. These studies used
subjective tests to detect IAN disorders.
Furthermore, this evaluation becomes dif-
ficult, because alterations in the IAN can
be caused by displacement of the frac-
ture36 (with IAN impairment present pre-
operatively) or by the manipulation used
to reduce the fracture intraoperatively16,38.
On analyzing the data, it was noticed

that the 3D plates performed better in
regions such as the condyle, with good
success rates. The success rates were com-
paratively lower in the areas of higher
tension forces, mainly dentate areas. Fur-
ther studies are needed to confirm this
finding.
In this review, there was a lack of

information and standardization among
the studies, making it difficult to draw
conclusions with solid evidence on the
indications for the use of 3D plates in
the treatment of mandibular fractures.
However, through this systematic review,
with cautious interpretation of the results,
it is suggested that more randomized, pro-
spective and controlled clinical studies are
performed to develop a safe protocol for
the use of 3D plates in mandibular frac-
tures.
3D plates can be used with some degree

of safety in non-displaced or mildly dis-
placed fractures, even in the region of the
mandibular angle. There is clear demysti-
fication of some advantages of these 3D
plates, but they are a viable option.

Funding

Not applicable.

Competing interests

None.

Ethical approval

Not applicable.

Patient consent

Not applicable.

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Address:
Júlio César Silva de Oliveira
Dental School at Araraquara – UNESP
Humaitá St.
1680
Araraquara
SP 14801-903
Brazil
E-mail: oliveirajulius@yahoo.com.br

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mailto:oliveirajulius@yahoo.com.br

	Three-dimensional strut plate for the treatment of mandibular fractures: a systematic review
	Materials and methods
	Search strategy and selection criteria
	Data extraction
	Quality assessment

	Results
	Discussion
	Funding
	Competing interests
	Ethical approval
	Patient consent
	References