Clinical Pearls in Reconstruction Plate Application

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Sağaltıcı S.

Turkish Association of Oral and Maxillofacial Surgery (TAOMS) 32. Uluslararası Bilimsel Kongresi, Antalya, Turkey, 5 - 09 November 2025, pp.385-391, (Full Text)

  • Publication Type: Conference Paper / Full Text
  • City: Antalya
  • Country: Turkey
  • Page Numbers: pp.385-391
  • Open Archive Collection: AVESIS Open Access Collection
  • Istanbul University Affiliated: Yes

Abstract

Clinical Pearls in Reconstruction Plate Application

 

Abstract

Objective:
Pathologic fractures of the mandible represent a major complication in the surgical treatment of large cysts and benign tumors. This study aimed to evaluate the indications and limitations of reconstruction plate application and to assess its role in preventing mandibular pathologic fractures.

Materials and Methods:
A retrospective analysis was conducted on patients treated at Istanbul University between November 2024 and October 2025. Inclusion criteria were mandibular cysts or benign tumors requiring enucleation, curettage, or resection with concomitant reconstruction plate placement. Malignant lesions, trauma history, and systemic conditions impairing bone healing were excluded. Demographic, clinical, and surgical data were reviewed. Outcomes included plate indications, complications, and postoperative follow-up of at least 6 months.

Results:
Seven patients (6 males, 1 female; mean age: 46 years) met the inclusion criteria. The most frequent indication for plate application was marked cortical thinning and large bony defects. Lesions were predominantly located in the mandibular body, followed by the angle and symphysis regions. During a mean follow-up of 10 months, no pathologic fractures were observed. Complication rates were low, with no plate exposure, loosening, or fracture, and only one case of localized infection.

Conclusion:
Reconstruction plates are an effective preventive measure against mandibular pathologic fractures in high-risk cases. Proper case selection and surgical experience are critical for minimizing complications. Prophylactic plate application can safely be performed under local anesthesia and remains a reliable strategy for maintaining mandibular integrity in benign lesions.

Key Words: mandibular fracture, reconstruction plate, benign pathology

Introduction


Pathologic fractures of the mandible represent a significant complication in the surgical management of large cysts and benign tumors. It has been reported that 81.8% of mandibular pathologic fractures are associated with radiolucent lesions [1]. The highest frequency of fractures has been observed in lesions located in the third molar region [2-4].

These lesions often cause marked thinning or destruction of the cortical bone, thereby increasing the susceptibility of the mandible to fracture either during or after surgery. Consequently, preventive stabilization methods such as reconstruction plates are widely employed to preserve mandibular integrity and to reduce fracture-related morbidity. However, the indications and limitations of plate use in benign pathologies remain controversial. While some authors advocate routine prophylactic plating in extensive defects, others recommend a more selective approach based on lesion size, location, and bone quality [5].

The aim of this study is to evaluate the indications and limitations of reconstruction plate application in such cases, to investigate its role in preventing pathologic mandibular fractures, and to provide clinical insights.

Results

A total of 7 patients (6 males, 1 female) who underwent surgical treatment for large mandibular cysts or benign tumors with reconstruction plate application were included in the study.

The most common indication for plate placement was extensive cortical thinning and large bone defects. Lesions were most frequently located in the mandibular body, followed by the angle and symphysis regions.

During a mean follow-up period of 10 months, no pathological fractures were observed in any of the cases.

Complications related to plate application were minimal. No plate exposure occurred, and localized infection was not observed. No plate fracture or loosening was recorded.

 

Discussion

Pathologic fractures of the mandible are among the most important complications in the surgical management of large cysts and benign tumors (Figure 1). The risk is particularly higher in the angle region, as masticatory forces and bending moments generated by hypertrophic masseter muscles impose the greatest load on the mandible in patients with molar occlusion(Figure 2 ). The position of the lesion, its inferior extension, and its relationship with the cortical plates are the most critical factors determining the likelihood of fracture. In our study, prophylactic rigid fixation was selectively applied in cases where the lesion approached the basal bone, where residual bone height was less than 10 mm, or where cortical perforation was present(Figure3). Conversely, in patients with intact basal and lingual cortices, a conservative approach was preferred, and no fractures occurred in these cases. The absence of pathologic fractures in patients who underwent simultaneous enucleation and reconstruction plate application confirms the protective role of rigid fixation when appropriately indicated.

Our findings are consistent with previous biomechanical and clinical studies. Murakami et al. used finite element analysis in a virtual environment to investigate stress distribution in the mandible after cyst enucleation and demonstrated that disruption of cortical continuity increases the risk of microdamage and pathologic fracture in the residual bone. The same study reported that miniplate placement significantly reduced stress concentrations, thereby highlighting the theoretical efficacy of reinforcement strategies [6]. These biomechanical data support the use of plates, particularly in lesions extending into the angle region and inferiorly.

In our series, preoperative three-dimensional (3D) models were generated and reconstruction plates were pre-bent prior to surgery (Figure 4). This workflow improved plate–bone conformity and contour accuracy, reduced intraoperative trial-and-error bending, and likely shortened operative time. It also limited periosteal stripping and facilitated soft-tissue preservation, while allowing pre-planned screw trajectories that respected tooth roots and the inferior alveolar canal. These practical advantages provide a direct bridge between the biomechanical rationale and the favorable clinical outcomes observed in our cohort.[7]

From a clinical perspective, reconstruction plates have been shown to be a reliable method in benign mandibular pathologies. İşler et al., in a retrospective study of 23 patients, reported that plate application was effective in preserving mandibular integrity, while the complication rates remained manageable. Although minor complications such as screw loosening, plate exposure, and paresthesia were observed, most of these were associated with disarticulation resections or the use of non-locking plates. The study specifically emphasized that locking plates reduced complication rates [8]. Similarly, in our series, no major complications were encountered despite the potential risks, underscoring the importance of surgical experience and appropriate case selection.

Considering the morbidity of a second surgical intervention in the event of a pathologic fracture, prophylactic plate application in high-risk cases protects patients from additional surgical trauma. Naturally, plate application also carries possible disadvantages (inferior alveolar nerve injury, screw loosening, infection, etc.). However, both the literature and our series demonstrate that the incidence of such complications in high-risk cases is low and far more tolerable compared to a pathologic fracture [6, 8].

In our study, all surgeries were performed under local anesthesia or local anesthesia with sedation support. This demonstrates that rigid fixation procedures can be safely performed without the need for general anesthesia. Nevertheless, certain limitations remain: inability to fully control muscle tone under local anesthesia, prolonged operative time, and the exclusion of cases extending to the condyle are among the main ones.

 

Clinical Pearls 

  1. Identify high-risk cases early: Large defects at the angle/body, residual bone height ≲10 mm, or basal bone/lingual cortex compromise → consider prophylactic rigid fixation. ; third-molar region carries elevated fracture risk. 
  2. Plate before or concomitant with lesion removal to prevent intraoperative green-stick fractures; FEM shows plating reduces stress concentrations after cyst/tumor surgery.  
  3. Choose a load-bearing 2.4 mm locking reconstruction plate for extensive cortical thinning; aim for ≥3–4 bicortical screws per side and overlap 2–3 holes onto healthy bone.  
  4. Inferior border placement with anatomic contouring respects mandibular biomechanics and reduces failure risk in the angle region. 
  5. Preoperative imaging and planning: Use CBCT-based planning to optimize screw trajectories and plate adaptation. Favor bicortical fixation along the inferior border and monocortical screws superior to the canal to protect tooth roots and the inferior alveolar nerve. In suitable cases, virtual surgical planning (VSP) with pre-bent/patient-specific platesmay shorten operative time and improve fit.
  6. Safe screw trajectory: avoid tooth roots and the inferior alveolar canal; bicortical purchase when feasible.  
  7. Locking systems may reduce complications (loosening/exposure) while preserving continuity in benign disease. 
  8. Soft-tissue principles: minimal periosteal stripping, tension-free closure → lower exposure/infection rates. 
  9. Anesthesia & aftercare: local (±sedation) is feasible in selected cases; soft diet and activity restriction help mitigate fracture risk. 
  10. Follow-up: ≥6–10 months without pathologic fracture supports the preventive role of plating when case selection is correct. 

Conclusion


Reconstruction plates represent a reliable preventive approach for maintaining mandibular integrity in the surgical management of large cysts and benign tumors. Their use is particularly beneficial in high-risk cases with cortical thinning, basal bone involvement, or large defects. When applied with proper case selection and surgical expertise, prophylactic rigid fixation effectively reduces the risk of pathologic fracture with minimal complication rates. Thus, reconstruction plate application should be considered as a safe and valuable adjunct in the management of benign mandibular pathologies.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

1.             Grau-Manclús, V., et al., Mandibular Fractures Related to the Surgical Extraction of Impacted Lower Third Molars: A Report of 11 Cases. Journal of Oral and Maxillofacial Surgery, 2011. 69(5): p. 1286-1290.

2.             Wagner, K.W., et al., Pathological mandibular fractures following third molar removal. International Journal of Oral and Maxillofacial Surgery, 2005. 34(7): p. 722-726.

3.             Iizuka, T., S. Tanner, and H. Berthold, Mandibular fractures following third molar extraction: A retrospective clinical and radiological study. International Journal of Oral and Maxillofacial Surgery, 1997. 26(5): p. 338-343.

4.             Krimmel, M. and S. Reinert, Mandibular fracture after third molar removal. Journal of Oral and Maxillofacial Surgery, 2000. 58(10): p. 1110-1112.

5.             Boffano, P., et al., Pathological mandibular fractures: a review of the literature of the last two decades. Dent Traumatol, 2013. 29(3): p. 185-96.

6.             Murakami, K., et al., Theoretical Efficacy of Preventive Measures for Pathologic Fracture After Surgical Removal of Mandibular Lesions Based on a Three-Dimensional Finite Element Analysis.Journal of Oral and Maxillofacial Surgery, 2014. 72(4): p. 833.e1-833.e18.

7.             Bhatt, M.A., et al., Use of Virtual Surgical Planning in Oral Surgery: A Systematic Review. Cureus, 2025. 17(3).

8.             Isler, S.C., et al., The use of reconstruction plates to treat benign mandibular pathological lesions: A retrospective clinical study. Journal of Stomatology, Oral and Maxillofacial Surgery, 2018. 119(5): p. 379-383.

 

 


 

Figures

 

 

Figure 1: (A) Preoperative panoramic radiograph showing a large mandibular cyst. (B) Postoperative panoramic view following surgical management and reconstruction plate application.

 

 

 

Figure 2:  A) Large lesion located in the mandibular angle region. (B) Postoperative radiograph following surgical management and reconstruction plate fixation.

 

 

 

 

Figure 3: (A) Mandibular lesion with perforation extending close to the basal border, indicating a high risk of fracture. (B) Postoperative panoramic radiograph following surgical management and reconstruction plate application.

 

 

Figure 4: Pre-bent reconstruction plate adapted on the mandibular model.