Management for the rehabilitation of atrophic mandible fracture: case using a conservative approach and short implants

The treatment of atrophic jaw fracture is a challenge in maxillofacial surgery, due to both local and systemic factors of the affected patients. This article aims to report a case of bilateral atrophic fracture of the mandible treated with an intraoral approach through a thinner and locked 2.0 mm system mandibular plate and subsequent rehabilitation with an implantsupported prosthesis. This technique provided the patient with excellent masticatory, aesthetic, and functional recovery with less morbidity and faster recuperation.


Introduction
Edentulism is a condition present in the great majority of the elderly and results in the atrophy of the involved bone, either maxilla or mandible (Oliveira et al., 2015). Mandibular atrophy causes a great decrease in vascularization and bone mass (Chee et al., 2014;Tiwana et al., 2009) with this the bone becomes more vulnerable to fractures and makes repair difficult (Wittwer et al., 2006;Ellis III et al., 2008;Madsen et al., 2009).
The treatment of atrophic jaw fracture is a challenge in maxillofacial surgery, due to both local and systemic factors of the affected patients. Difficulties in fracture reduction and immobilization can result in unsatisfactory bone repair, as well as poor bone quality and poor vascularization may add to the problem (Vajgel et al., 2013;Clayman et al., 2012). Other point is those patients are many time systemically compromitted. Usually require overtime hospitalization and intensive care units can be necessary.
The literature describes several ways for the rehabilitation of atrophic jaws, including grafts, alveolar nerve lateralization, and short implants (Bell et al., 2009;Pistilli et al., 2014;Duttenhoefer et al;Peñarrocha-Oltra et al., 2014). Patients rehabilitated with osseointegrated implants after mandibular fractures have a good prognosis, with the recovery of quality of life, chewing, aesthetics, and phonetics.
This article aims to report a case of bilateral atrophic fracture of the mandible treated with a conservative approach performing to intraoral incision and two bilaterall small transcutaneous incision. Then a thinner and locked 2.0 mm system mandibular long plate and subsequent rehabilitation with implant supported prosthesis.

Methodology
This clinical case report is part of a descriptive observational study, which in addition to discussing the proposed treatment, also aimed to discuss the topic through the bibliographic survey carried out (Ribeiro-Júnior et al., 2018;Klein et al., 2019). And thuscontribute to the scarce scientific literature on the subject. Thus representing a descriptive and qualitative content. The case was conducted according to clinical and professional ethics. The patient reported in the study has a personal data sheet and anamnesis, where he authorized the use of images, clinical, radiographic and socioeconomic data for educational and research purposes, and with this signed a Free and Informed Consent Form and the Informed Consent Form.
Consent of the Person's Participation as a Subject, which were duly read and explained.

Case reporte
EB patient, 87 years old, suffered a fall from the height that caused a facial trauma. Medical history with cardiopathies and emphysema. Clinical examination showed mobility and bone crepitation in a region of bilateral parasyphysis, paresthesia in the region of the lower lip and sublingual hematoma. In the radiographic and tomographic imaging studies, bilateral mandible fracture traces were observed in the region of the parasymphysis (Figure 1). One 3D mandible model was requested with the purpose of pre-bending of the plate pre-operatory, thus reducing the surgical time (Figure 2). In the surgical procedure, under general anesthesia, an intraoral approach was performed in the region of the alveolar mucosa from the left to the right mandibular angle, maintaining the integrity of the mental nerves. The anterior segment of alveolar neve was displacement to superior. The fracture was anatomically reduced and fixed with 2.0 mm locking long plate and 2.0 mm screws (Figure 3). Two small submandibular transcutaneous approaches were performed on each side that allowed access to the more proximal screws. The surgical time was 92 minutes and the patient were discharged 24 horas of the surgery. He did not need to go the intensive care. After 5 months the patients were rehabilitated with four dental implants and immediate loading in the office. (Figure 4). Research, Society andDevelopment, v. 10, n. 4, e4611424249, 2022 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i4.24249

Results and Discussion
Open reduction and fixation with plates and screws are currently considered the most effective treatment for fixation of mandibular fractures (Mugino et al., 2005). In edentulous patients, most of the time, mandible atrophy and, consequently, loss of bone height makes it difficult to use a miniplate in the tension zone and a fracture compression zone. In these cases, the preferred osteosynthesis is the mandibular reconstruction plates of the 2.4 mm system (conventional or Locking) (Ellis III et al., 2008) The use of the 2.0 mm Locking system presents some advantages that are the reduction of the surgical time, easiness of adaptation, when compared to the 2.4 mm plate, and good stability of the bone segments and less morbidy (Junior RC et al., 2017). The possibility of using these with intraoral approach allows faster recovery of the patient.8 Despite being thicker, 2.0mm Locking plates can provide bone stability similar to that provided by a 2.4mm reconstruction plate (Junior RC et al., 2017;Zhan et al.,2014). The 2.0 locking screw/plate systems may be another alternative for the treatment of atrophic mandible fractures via an intraoral approach, allowing faster recovery.
The possibility of rehabilitation after atrophic mandible fractures with short implants without using reconstructive procedures with bone graft is an attractive option.1 In some cases, it's necessary virtual planning for a correct position of implants away from the osteosynthesis screws at the symphysis area.9 The risk of mandibular fracture atrophic after dental implants is decreased because, before the implantation, a reconstruction plate was placed.10-12 (Ribeiro-Júnior et al., 2018;Klein et al., 2019)

Conclusion
The 2.0 locking screw/plate systems may be another alternative for the treatment of atrophic mandible fractures via intraoral approach. This alternative treatment in fracture shows effective, less morbidity and provided here predictable, fast, aesthetic and functional rehabilitation of the patient.