Usefulness of the retromandibular transparotid approach for condylar neck and condylar base fractures

Condyle fractures represent 20% to 30% of all mandibular fractures and are thus among the most common facial fractures. The fracture pattern can vary greatly and may occur anywhere along the line from the sigmoid notch to the mandibular angle. The main problems are access, difficulty in repositioning the extremely slender fragments, and fixation of the condyle.Eighty-seven patients were diagnosed with condylar neck or condylar base fractures from January 2007 to December 2009 in the Department of Oral & Maxillofacial Surgery of Kyung Hee University Dental Hospital. In this study, we included 35 patients who underwent open surgery and a total of 28 patients who were treated using a retromandibular transparotid approach.Surgical treatment aims were anatomic repositioning and rigid fixation of the fragments, occlusal stability, rapidly return to function, maintenance of vertical ramus dimension, no airway compromise, and reduced long-term temporomandibular joint dysfunction. Considering the high rate of occurrence of condylar fracture and the importance of the condylar as a growth center of the mandible, extraoral approaches for the open reduction of condylar fractures are considered effective and can be used widely.Short access route, easy reduction, short operating time, and stable postoperative occlusion are the advantages of the retromandibular transparotid approach. Also, there was no permanent damage from facial nerve injury, salivary leakage, or preauricular hypoesthesia. Therefore, the retromandibular transparotid approach is considered a safe and effective method for patients with a condylar neck or condylar base fracture classified according to the Strasbourg Osteosynthesis Research Group's classification, who require surgical treatment with an extraoral approach.     

穿腮腺入路治疗髁颈及髁突基底部骨折

目的：探讨穿腮腺入路治疗髁颈及髁突基底部的安全性及有效性。方法：对15例（21侧）髁颈及髁突基底部骨折患者选择穿腮腺入路切开复位内固定术。结果：15例患者,21例侧髁突骨折行手术治疗。19例侧髁突骨折选择2块接骨板固定,2例侧选择1块接骨板固定。所有患者伤口均一期愈合,术后复查全口曲面断层片或三维CT示骨折断端对位良好。除1例患侧后牙暂时性轻度开外,所有患者咬合关系恢复良好。术后1个月复查,张口度32～45mm（平均38mm）。3例侧出现面神经损伤症状,术后3个月内均恢复正常,无1例出现永久性面瘫。所有患者均未出现涎瘘、感染等并发症。结论：相对于髁突骨折的颌后及颌下入路,穿腮腺入路行髁突骨折切开复位内固定术,容易暴露,可直视下完成骨折复位固定,是治疗髁颈和髁突基底部骨折安全有效的手术入路。     

24例髁突骨折经下颌后进路行坚强内固定的疗效观察

目的:介绍发生于髁突颈和髁颈以下髁突骨折用小型钛板经下颌后进路行解剖复位、坚强内固定术的方法和经验。方法:发生于髁突颈和髁颈以下骨折24例30侧,经下颌后进路以小型钛板行坚强内固定术。术后3～6个月后复查并评价疗效,复查内容包括:张口度、张口型、咬合关系、X线表现、面神经损伤情况。结果:张口度较术前明显增大,张口型偏移明显改善,错牙合3例,面神经下颌缘支损伤2例。X线检查:髁突骨折复位良好,髁突无移位。结论:下颌后进路是一种治疗髁突颈和髁颈以下骨折的有效方法。     

经腮腺入路复位固定下颌骨骨折

目的：探讨经腮腺入路行髁突低位骨折和下颌支骨折切开复位内固定的可行性。方法：对22例低位髁突骨折和4例下颌支骨折采用经腮腺入路行切开复位内固定术。结果：26例（100％）均使用2块接骨板固定,26（100％）例咬合关系基本恢复到伤前情况,术后开口度26～48mm（平均38．3mm）。2例（8％）出现面神经颊支损伤症状,3个月内均恢复正常,未出现面神经永久损伤病例及涎漏等并发症。结论：经腮腺人路行髁突低位骨折和下颌支骨折解剖复位坚强内固定,视野暴露好,复位固定可靠,面神经损伤较少。     

Retromandibular transparotid approach compared with transmasseteric anterior parotid approach for the management of fractures of the mandibular condylar process: a prospective randomised study

Fractures of the mandibular condyle lead to displacement of the condyle and loss of the height of the ramus. A retromandibular approach is the most commonly used for open reduction and internal fixation (ORIF) of such fractures. We aimed to compare the complications associated with a retromandibular transparotid approach with a retromandibular transmasseteric anterior parotid (TMAP) approach for their management. Thirty patients were randomly selected into two groups (15 in each): Group A comprised the retromandibular transparotid approach and Group B the retromandibular TMAP. The variables evaluated were: operating time, facial nerve injury, occurrence of Frey syndrome, and sialocoele at one week, four weeks, three months, and six months. The mean (SD) age in group A and B was 33.93 (17.97) years and 33.53 (16.15) years, respectively, and there were 28 men and two women. Mean (SD) exposure time in the transparotid approach was 26.93 (5.19) minutes and 25.4 (8.35) minutes in the TMAP approach. The incidence of facial nerve injury was 2/15 patients in the transparotid group and 3/15 in the TMAP group, all of which resolved within six months. The incidence of sialocoele was 2/15 in the transparotid group. The results did not show any significant difference in complications between the two approaches, but the retromandibular transparotid approach provided straight-line access in fractures of the condylar neck, with fewer incidences of nerve injury. The anterior parotid approach, on the other hand, provided easier access for fractures that were medially dislocated or of the condylar base but had an increased incidence of facial nerve injuries.     

Comparison of various approaches for the treatment of fractures of the mandibular condylar process

Fractures of the mandibular condyle process are the most common fractures of the lower jaw. Unfortunately, the type of treatment is still a matter of debate.PurposeThe aim of this investigation was to compare the outcome of different treatment approaches regarding function and surgical side-effects.Patients and methods111 fractures of the mandibular condyle representing all types according to the classification of Spiessl and Schroll were included. Both closed reduction (CR) and open reduction with internal fixation (ORIF) including the retromandibular/transparotid, submandibular, preauricular and intraoral approach were performed. The clinical examination included functional and aesthetic aspects at least 1 year after the fracture.ResultsThe majority of fractures (45%) were classified into Type II and IV according to Spiessl and Schroll followed by fractures without any displacement or dislocation (29.7%). The submandibular approach showed the worst outcome regarding permanent palsy of the facial nerve and hypertrophic scarring. No significant differences between the various approaches were detected in the functional status in any diagnosis group.ConclusionInferior condylar neck fractures benefit from ORIF by an intraoral approach whereas in high condylar neck fractures the retromandibular/transparotid approach shows the best results. Fractures of the condylar head were almost all treated by CR and our results cannot contribute to the debate of CR vs. ORIF in this type of fracture.     

穿腮腺手术径路治疗下颌骨髁突骨折的临床效果评价

目的评价穿腮腺手术径路治疗下颌骨髁突骨折的临床效果。 方法对31例（共36侧）下颌骨髁突骨折的患者,穿腮腺入路行下颌骨髁突骨折切开复位钛钉钛板坚固内固定术、髁突骨折碎片取出术并髁突成形术。术后观察面型、张口度、咬合关系、面神经损伤、有无唾液腺瘘及复查颌面部CT观察骨折段的复位情况等。 结果24例（共29侧）行下颌骨髁突骨折切开复位钛钉钛板坚固内固定术,7例（共7侧）髁突骨折碎片取出术并髁突成形术,术后随访6 ~ 18个月（平均11.3个月）;通过穿腮腺手术径路骨折断端复位准确、固定良好、咬合功能恢复正常、面部外形均满意;4例患者早期出现Ⅰ~Ⅱ度张口受限,经过张闭口训练后恢复正常;5例患者出现面神经暂时性麻痹,8周后均恢复正常;1例患者出现唾液腺瘘,经过加压包2周后扎后创口愈合;4例患者出现创伤性关节紊乱症,有关节弹响、疼痛等。 结论穿腮腺手术径路治疗下颌骨髁突骨折安全有效,手术并发症少,值得临床推广应用。     

3种不同手术入路治疗成人髁突骨折效果分析

目的 ：探讨成人髁突骨折3种不同手术入路的临床疗效。方法 ：46例共48侧成人髁突骨折按Loukota等标准分类,根据分类分别采用耳屏前入路、颌后穿腮腺入路及口内入路进行复位内固定。结果：46例患者术后下颌运动及咬合关系恢复良好,开口度基本正常,骨折复位及愈合良好,髁突未见明显吸收。结论：根据成人髁突不同骨折类型,灵活采用不同手术入路,可获得满意的临床效果。     

Retromandibular approach for reduction and fixation of mandibular condylar fractures: A clinical experience

This study evaluated the efficiency and safety of a retromandibular approach to reduce and fix displaced condylar fractures. The study group included 31 patients who had undergone surgery for 35 condylar fractures (8 bilateral, 23 unilateral). Consultants and residents had performed the procedure. Inclusion criteria were: patient's choice for open reduction and fixation; displaced unilateral condylar fractures with occlusal derangement; bilateral condylar fractures with anterior open bite. Restriction of lateral movement towards the unaffected side was observed preoperatively in all cases taken up. There was a difference in the lateral movements towards the fractured side (mean 7.2) and unaffected side (mean 4.2) during the first postoperative review. Functional occlusion identical to the preoperative occlusion and good reduction of the condyles was noted in all cases. Facial nerve was encountered in 6 cases (17%) intraoperatively. There was one case (3%) of temporary facial nerve weakness, which resolved within 2 weeks. There was no permanent facial nerve damage in any patient. The retromandibular-transparotid approach seems to be a safe and efficient method for reduction and internal fixation of condylar fractures with little or no risk to the branches of facial nerve.     

Evaluation of facial nerve following open reduction and internal fixation of subcondylar fracture through retromandibular transparotid approach

The objective of this study was to evaluate any damage to the facial nerve after a retromandibular transparotid approach for open reduction and internal fixation (ORIF) of a subcondylar fracture. We studied 38 patients with 44 subcondylar fractures (3 bilateral and 38 unilateral) treated by ORIF through a retromandibular transparotid approach. All patients were followed up for 6 months. Postoperative function of the facial nerve was evaluated within 24 h of operation, and at 1, 3, and 12 weeks, and 6 months. Variables including type of fracture, degree of mouth opening, postoperative occlusion, lateral excursion of the mandible, and aesthetic outcome were also monitored. Nine of the 44 fractures resulted in transient facial nerve palsy (20%). Branches of the facial nerve that were involved were the buccal (n = 7), marginal mandibular (n = 2), and zygomatic (n = 1). In the group with lateral displacement, 2/15 showed signs of weakness, whereas when the fracture was medially displaced or dislocated 7/23 showed signs of weakness. Of the 9 sites affected, 7 had resolved within 3 months, and the remaining 2 resolved within 6 months. The mean (range) time to recovery of function was 12 weeks (3–6 months). There was no case of permanent nerve palsy. The retromandibular transparotid approach to ORIF does not permanently damage the branches of the facial nerve. Temporary palsy, though common, resolves in 3–6 months. Postoperative occlusion, mouth opening, and lateral excursion of the mandible were within the reference ranges. We had no infections, or fractured plates, or hypertrophic or keloid scars.     

The retromandibular transparotid approach to mandibular subcondylar fractures

The aim of this study was to evaluate the safety, utility and morbidity associated with the treatment of mandibular subcondylar fractures using the retromandibular transparotid approach and to evaluate the stability of a single 2mm miniplate fixation system for such fractures. Forty-two cases with 48 mandibular subcondylar fractures were analysed prospectively for 12 months and evaluated for functional results, scar, postoperative complications and stability of fixation. There were three cases of suboptimal occlusal status, two cases of haematoma that were drained and resolved, eight patients with facial nerve weakness which resolved in a few weeks, and three cases of salivary fistulae that resolved after treatment. All cases showed stable osteosyntheses. Maximal postoperative interincisal distance was 32-61 mm (mean 44 mm). Four patients had deflection on opening, while clicking on opening or chewing was observed in five patients. The postoperative scars were well accepted by all patients. The results of this study suggest that a retromandibular approach will facilitate accurate reduction and fixation of subcondylar fragments with a good cosmetic result and minimal complications. A single 2 mm miniplate fixation provides stable results.     

Preliminary functional results of endoscope-assisted transoral treatment of displaced bilateral condylar mandible fractures

Temporomandibular joint (TMJ) function was evaluated following endoscope-assisted transoral open reduction and miniplate fixation of displaced bilateral condylar mandibular fractures. The transoral treatment of bilateral condylar fractures was performed in 13 patients from May 2000 to December 2004. Eleven of the 13 patients had additional mandibular fractures. Out of 26 fractures of the condylar process, 11 were located at the condylar neck and 15 were subcondylar. One, 6 and 12 months after surgery TMJ function was evaluated. Anatomic reduction was achieved using an endoscope-assisted transoral approach even when the condylar fragment was displaced medially and in fractures with comminution. Good TMJ function was noted 6 and 12 months after surgery. Mouth opening was measured to be more than 40 mm without deviation. Postoperative range of motion with a satisfying lateral excursion was found. Early rehabilitation and pre-injury TMJ function was achieved following minimally invasive anatomic fracture reduction.     

髁突骨折解剖复位及小型接骨板坚强内固定

目的 探讨髁突骨折解剖复位和小型接骨板坚强内固定的技术要点和并发症的发生因素。方法 髁突骨折72例97侧（单侧47例,双侧25例）。陈旧性骨折12例,髁颈和髁颈下骨折81例,移位和脱位骨折90例。8侧未手术,7侧髁突摘除,6侧升支垂直截骨间接复位,76侧直接复位。59侧单板固定,21侧双板固定,2侧螺钉穿接固定,有22侧髁突呈游离再植,68例经颌后入路,21侧经耳屏前入路。术后1～3个月复查9例,3～6个月36例,6个月以上27例,复查内容包括骨折复位准确性、固定稳定性、骨折愈合改建,伤口愈合、面型、he关系、下颌运动、关节症状、神经损伤。结果 感染2侧,错he2例,假关节2侧,接骨板断裂3侧,接骨板变形2侧,骨折块再移位7侧,髁突吸收6侧,张口受限7例,关节疼痛5侧,关节杂音5侧,面神经损伤9例。并发症发生率33%（24/72例）,排除医源性因素后的并发症率14%（10/72例）。结论 切开复位及小型接骨板坚强内固定是治疗髁颈和髁颈下移位及脱位骨折的效方法,升支垂直截骨髁突游离再植是治疗髁突陈旧性骨折的可选择方法。低位髁颈和髁颈下骨折应采用颌后入路,接骨板应沿后外缘作张力带固定,髁颈下严重移位和陈旧性骨折需在髁颈前或乙状切迹处增加补偿固定。     

翼外肌-髁突解剖复位内固定治疗髁突骨折的探讨

目的:探讨髁突骨折进行解剖复位和小型钛板坚强内固定的手术适应证、方法和治疗效果。方法:以髁头脱位骨折、髁颈和髁颈下骨折移位角度大于30°～45°、下颌支垂直高度降低超过4～5mm为适应证,对收治的23例28侧髁突骨折患者采用改良耳颞部"拐杖"型切口或颌后进路,行翼外肌-髁突解剖复位及张力带小型钛板坚强内固定。术后3～6个月复诊,检查面型、开口度、开口型、咬合关系、咀嚼力,并以此进行疗效评价。结果:所有患者面型对称,开口度较术前明显增大,开口型显著改变。2例术后错牙合患者经1周颌间牵引,恢复正常。影象学检查示髁突无移位,骨折无错位。钛板无移位,髁突表面无明显吸收现象。患者咀嚼有力。2例面瘫患者经治疗后3个月恢复。结论:选择合适病例,进行翼外肌-髁突开放性解剖复位固定,是一种既能恢复解剖形态又能恢复咀嚼功能的有效方法。     

The periauricular transparotid approach for open reduction and internal fixation of condylar fractures.

INTRODUCTION: Treatment of fractures of the mandibular condyle fractures varies among centres as there still is no general consensus. The aim of this paper was to determine the safety and efficiency of surgical treatment using a transparotid approach for direct plating. PATIENTS AND METHODS: A prospective clinical study was conducted on 34 patients with 36 fractures of the condyle. All 36 fractures were displaced, and 14 (39%) of them were fracture dislocations. The fractures were treated surgically with a transparotid facelift or retromandibular approach using miniplates and screws for fixation. Patients were carefully followed up and were asked to answer a survey paper 2-39 months postoperatively. RESULTS: Occlusion practically identical to the pretraumatic condition was achieved in 31 out of 33 dentate patients (94%). Postoperative interincisal distance was 30-61 mm (mean 44 mm), 4 patients (12%) had postoperative deflection to the side of injury during mouth opening. Facial symmetry was achieved in all of the patients. Eight out of 36 cases (22%) had a transient weakness of certain ipsilateral facial muscle groups, lasting for 4-8 weeks. In one of these patients, a mild weakness of the upper lip and lower eyelid persisted after 13 months. There were 5 cases of miniplate fractures (14%), all of them in patients in whom 1.7 or thinner miniplates were used. There were 5 cases of salivary fistulae (14%), all of them in patients where the parotid capsule was not closed in a watertight fashion. According to the postoperative survey completed by 32 patients, 30 of them (94%) were very satisfied with the outcome of treatment. CONCLUSION: If conducted properly, the transparotid facelift approach offers a safe and effective approach for direct fixation of condylar fractures.     

Transmasseteric anterior parotid approach for condylar fractures: experience of 129 cases

We have evaluated the transmasseteric anterior parotid (TMAP) approach in the treatment of 163 condylar fractures in 129 patients. Ninety-five patients presented with unilateral, and 34 with bilateral, fractures. The inclusion criteria were patient's choice for open reduction and internal fixation, displaced unilateral condylar fractures with occlusal derangement, and displaced bilateral condylar fractures with anterior open bite. Mean (SD) maximum interincisal opening after 3 months was 44(5)mm. There were no differences in lateral movements during the reviews 6 weeks and 3 months postoperatively. Protrusive movement at the end of 3 months was 7(2)mm. All patients achieved functional occlusion identical to the pretraumatic occlusion and good reduction of the condyles. No patient developed temporary or permanent facial palsy, sialocele, salivary fistula, or Frey syndrome. The mean (SD) operating time was 46(11)min. The TMAP approach avoids the complications of incision of the parotid gland, minimises the risk of facial nerve palsy, and offers excellent access to the fractured condyle.     

Open Reduction Internal Fixation of Condylar Head/Diacapitular Fracture of Mandible: Case Series

ObjectiveSurgical management of condylar head is largely deferred due to the lack of appropriate armamentarium or instrumentation, restricted surgical access and risk of iatrogenic complications. Here we delineate open reduction internal fixation of condylar head fracture with various fixation modalities using specialized instrumentation for visualization and providing access for reduction with minimal complications.MethodsA total of 21 patients were reported with condylar head fracture of mandible to the Department of Oral and Maxillofacial Surgery from January 2017 to June 2018. Three patients had bilateral condylar head fracture, making it a total of 24 fractures. All patients had clinical symptoms including deranged occlusion, limited mouth opening, jaw deviation and restricted mandibular movements. The radiological findings were dislocated or displaced condylar head medially or laterally. All patients were treated by open reduction internal fixation using lag screws or standard long screws.ResultsAmong condylar head fractures, 19 of the study population were male and 2 were female. Distribution of age among the condylar head fractures ranges from 19 years to 40 years with the mean being 22 years. At the end of three-month follow-up, all patients had satisfactory results, both clinically and radiologically. The functional outcome of this study was found to be superior.ConclusionWe recommend open reduction internal fixation of condylar head for patients with high risk of ankylosis, and it is possible without complications due to the availability of minimally invasive surgical access system.     

How to improve retromandibular transmasseteric anteroparotid approach for mandibular condylar fractures: our clinical experience

Fractures of the mandibular condyle are common and account for 25–35% of all mandibular fractures reported in the literature. Even with the development of a consensus on the preference for open reduction and internal fixation of these fractures, the clinician is still faced with a dilemma concerning the optimal approach to the ramus–condyle unit. Limited access and injury to the facial nerve are the most common problems. The most commonly used extraoral approaches are the submandibular, retromandibular and preauricular methods. In this study, we propose a modified cosmetic preauricular incision with a short end in the neck, to improve the transmasseteric anteroparotid (TMAP) approach previously described by Wilson et al. in 2005. We retrospectively analysed 13 patients treated in our department for mandibular condylar fractures. Post-operative complications, occlusal status, interincisal opening and joint tenderness were evaluated at 3 months after surgery. The wider skin incision described here provides a convenient approach for open reduction and rigid internal fixation, and good results were obtained. The follow-up ranged from 6 to 40 months.     

A preauricular long-corniform approach for open reduction and internal fixation of mandibular condylar fractures

IntroductionWe report functional and clinical outcomes following use of a preauricular long-corniform incision for open reduction and internal fixation (ORIF) of mandibular condylar fractures.Materials and methodsPatients with mandibular condylar fractures who underwent ORIF via a 120° preauricular long-corniform incision were included in the study. A total of 78 patients (100 condyles) were included. Follow-up occurred 10 days and 1–6 months after surgery, and included assessments of clinical, functional outcome, complications, and bone fusion.ResultsThere were 38 high neck, 26 low base, and 35 diacapitular condylar fractures. All measures of functional outcome significantly improved over time after surgery regardless of fracture type (all P < 0.001). The vast majority of patients in all fracture type groups had good occlusion (≥88.5%), no pain (≥89.5%), and anatomical reduction 10 days after surgery (≥81.6%). Fracture healing was complete in all patients after 6 months. There were no long-term complications and all patients were satisfied with their postoperative appearance.ConclusionsOur findings suggest that a preauricular long-corniform incision provides a good visual field during surgery, and allows for effective ORIF of mandibular high neck, low base, and diacapitular condylar fractures, with positive outcomes and minimal postoperative complications.     

38例下颌骨髁突囊内骨折的手术治疗及疗效评价

目的： 介绍一种改良的下颌骨髁突囊内骨折（diacapitular condylar fractures, DCF）手术治疗方法，并评价其疗效。方法： 2015年1月—2016年12月期间，对38例（50侧）DCF患者进行骨折内固定联合颞下颌关节盘锚固术治疗。采用改良耳前入路，复位骨折髁突并用1颗长14~16 mm的螺钉固定，然后复位向前内侧移位的关节盘，并用1颗锚固钉锚固于髁突后斜面下缘中份。所有患者进行手术前、后颌面部CT、颞下颌关节 (temporomandibular joint, TMJ) MRI 检查，对伴有下颌骨其他部位的骨折，同期进行解剖复位、固定。利用SimPlant Pro 11.04软件 CMF模块进行术前、术后，健侧、患侧下颌支高度测量，并进行配对t检验，评价骨折固定效果。利用术前、术后MRI中关节盘与髁突顶点相对位置的变化，评价关节盘锚固术的准确性。术后对所有患者进行随访，对开口度、开口型、关节弹响、面神经损伤症状等进行比较。采用SPSS 17.0软件包对数据进行统计学处理。结果： 手术后颌面部CT显示，37例（48侧）囊内骨折达到解剖复位（有效率96%）。所有患者患侧下颌支高度较术前显著增加（P<0.05）；19例单侧囊内骨折患者术后健、患侧下颌支高度无显著差异（P>0.05）。术后MRI图像显示，35例（46侧）关节盘回到原有的解剖位置，有效率为92.0%（46/50）。术后远期随访显示，38例患者咬合关系稳定，平均开口度35.67 mm，最大侧方咬合平均值为4.45 mm，最大前伸咬合平均值为5.63 mm；开口型偏斜2例（5.3%），关节弹响2例2侧（4.0%）；4例患者出现不同程度的暂时性面神经功能不全，其中3例在术后3个月逐渐恢复，另外1例（2.6%）随访3个月后仍出现患侧抬眉困难，口服甲钴胺片后症状缓解。结论： 下颌骨髁突囊内骨折常伴发TMJ关节盘移位，且方向与移位的骨折片一致。骨折开放复位内固定术联合颞下颌关节盘锚固术是治疗该类型骨折的有效方法。