Quality of life after open versus closed treatment for mandibular condyle fractures: A review of literature

IntroductionMany studies have compared treatment outcomes after open reduction and internal fixation (ORIF) and closed reduction (CR) of mandibular condylar fractures. Despite this the optimal treatment for these fractures remains a controversy. The purpose of this review is to compare the influence of objective and subjective treatment outcomes after open versus closed treatment of mandibular condyle fractures on quality of life, based on the current literature.MethodsA MedLine and Embase search was performed to find relevant titles on treatment outcomes after open versus closed reduction of mandibular condylar fractures.ResultsThirty-six studies were found. Twenty-eight retrospective studies, in addition to eight prospective studies were assessed. Nine treatment outcome variables were evaluated from the studies. Three studies reported on subjective discomfort. Although many studies investigated (objective) measurements (e.g. range of motion, masticatory function), no studies evaluated quality of life outcomes. In conclusion, prospective, patient-centred research is needed, in order to provide a guideline in decision making in the treatment of mandibular condylar fractures, based on subjective patient satisfaction.     

Mini-retromandibular access to the condyle in panfacial fractures

ABSTRACT: Surgical management of panfacial fractures can be extremely challenging. The many fracture lines and lack of landmarks make it difficult to restore the facial skeletal morphology. Extracapsular fractures of the mandibular condyle require open reduction and internal fixation to restore the vertical and sagittal dimensions of the mandible, representing the base for further facial skeleton reconstruction. Six patients with panfacial fractures, including a bilateral extracapsular condylar fracture, were treated between January 2006 and November 2009. One patient underwent surgical procedure 60 days after the injury. The condylar fractures were treated via a mini-retromandibular access. Overall, the bone morphology restoration was good. In particular, all of the condylar fractures were reduced satisfactorily. No complication was detected, and no facial nerve lesion was observed. The literature contains many proposals for surgically accessing panfacial fractures. Open reduction and internal fixation of condylar fractures are crucial for restoring face height. The mini-retromandibular access is especially suitable, because it allows safe, rapid surgical management.     

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.     

Mini-retromandibular approach to condylar fractures

INTRODUCTION: Among maxillofacial surgeons, a general agreement exists that the therapeutic strategy for intracapsular condylar fractures is conservative, while the treatment of extracapsular fractures of the mandibular condyle is extremely controversial. The indications and choice of treatment are less than uniform, often relying on the surgeon's personal experience and beliefs. The literature increasingly suggests that the surgical management of these fractures is superior to conservative management in functional terms. Nonetheless, the indications for surgically treating condylar fractures are limited by fear of potential pitfalls related to the access. Extraoral routes to the condyle involve the risk of facial nerve injuries or visible scars; transoral access is free from these pitfalls but is demanding technically, especially for higher neck fractures. In our experience, a 2-cm-long retromandibular access allows straightforward management of condylar fractures, providing as a result a well concealed scar. MATERIALS AND METHODS: From 2006 to 2007, 21 patients with 25 condylar fractures were treated surgically using the mini-retromandibular access. The mean operating time was 32min (range 17-55min). No facial nerve injuries were observed. The first two patients developed postoperative infections. One patient, in whom the first intervention resulted in malreduction of the fracture because the access was insufficient (15mm incision), required a second operation to achieve correct reduction and rigid fixation of the condyle. RESULTS: In all cases, good anatomical stump reduction was achieved. All the patients obtained good articular function, since the access was exclusively extra-articular. CONCLUSIONS: Condylar fracture reduction, fixation and healing can be managed comfortably using a limited retromandibular approach. Moreover, the risk of facial nerve injury is limited as the nerve fibres are viewed directly.     

Use of a temporary screw for alignment and fixation of sagittal mandibular condylar fractures with lateral screws

This study introduced and evaluated the clinical application of a temporary and lateral screw technique for open reduction and internal rigid fixation of sagittal mandibular condylar fractures. A preauricular approach was used to expose the fracture. A temporary screw was used to assist in the anatomical reduction, and a lateral lag screw in combination with a lateral position screw was used for internal rigid fixation. Six adult patients with sagittal condylar fractures and more than 5 mm condylar height shortening were treated. The treatment outcomes were followed up clinically and radiographically for 8–27 months (mean 18 months) postoperatively. There were no complications associated with the operation. All patients recovered favorably with good occlusion, normal movement of the mandible, correct repositioning and rigid fixation of the fragment of the fracture and a good condyle shape on radiographs. The temporary and lateral screw technique is a simple, effective, fast, and minimally invasive surgical treatment for adult sagittal condylar fractures.     

克氏针治疗下颌骨髁突矢状骨折13例回顾性分析

目的探讨克氏针内固定方式在下颌髁突矢状骨折治疗中的应用价值。方法回顾分析2019年1月至2020年1月在广州中医药大学附属佛山市中医院口腔医疗中心就诊的下颌骨髁突矢状骨折复位后采用克氏针内固定治疗的患者,共13例19侧。治疗过程包括常规手术切开、暴露并复位游离的下颌骨髁突后,根据下颌骨髁突骨质断端情况利用2~4根克氏针固定,伴发其他部位骨折时同期手术治疗。术后1周通过CBCT评估游离的下颌骨髁突复位精准度及稳固性,通过临床检查评价咬合关系、开口度、开口型。结果所有患者骨折断端对位良好,克氏针无扭曲、折断和松脱;术后咬合关系、开口度、开口型恢复良好。结论克氏针治疗下颌骨髁突矢状骨折效果确切,有临床应用价值。     

Fractures of the mandibular condyle: evidence base and current concepts of management

Management of mandibular condylar fractures remains a source of ongoing controversy. While some condylar fractures can be managed non-surgically, recognition of fracture patterns that require surgical intervention and selection of an appropriate operative procedure are paramount to success in treating these injuries.The objective of this review is to appraise the current evidence regarding the effectiveness of interventions that are used in the management of fractures of the mandibular condyle.     

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。     

Modified trans-oral approach for mandibular condylectomy

Different approaches to the mandibular condyle have been described. In this paper, a modified trans-oral technique to access the mandibular condyle is described and illustrated. This technique was used in a small group of patients; the clinical outcomes are promising. The technique can be used in various temporomandibular joint (TMJ) operations, such as condylar resection, high condylectomy or tumor removal. It provides adequate intra-oral surgical access to the mandibular condyle and avoids complications from extra-oral approaches to the TMJ.     

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.     

Articular soft tissue injuries associated with mandibular condyle fractures and the effects on oral function

The majority of studies debating the optimization of treatment for condylar mandibular fractures focus on the bony aspect first. However, fractures of the mandibular condyle may go together with soft tissue injury of the temporomandibular joint. An electronic literature search for this topic was undertaken. Assessment of quality was carried out using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Sixteen articles were included in this review. The reviewed literature showed that intracapsular fractures and dislocated condylar fractures result in more severe injuries. Serious injury to the disc and capsule of the temporomandibular joint is a contributing factor towards development of complications after closed treatment. The results of this review give an overview of the published studies focusing on articular soft tissue injuries caused by condylar mandibular fractures. Additionally, an overview of the magnetic resonance imaging (MRI) settings used to detect these injuries is provided. Until now, the relation between soft tissue injuries and type of condylar trauma and their influence on clinical outcome has been insufficiently investigated. Before considering reduction of soft tissues next to reduction of the fracture, more research is needed into the impact of soft tissue injuries on oral functioning, in which a uniform classification is used.     

Endoscopic treatment of mandibular condylar fractures in live minipigs: benefits of the operative learning curve

Endoscopic treatment of mandibular condyle fractures is a minimally invasive technique that avoids the complications of open reduction and internal fixation. We have used live minipigs as an animal model for learning and training the technique. Fourteen condylar fractures were created, reduced, and internally plated in 7 minipigs using an endoscopic approach by a surgeon with no previous experience of the technique. The mandibles were reduced and fixed successfully in each animal. Operating time was reduced as the surgeon became more familiar with the technique. Minipigs are useful as a model for the endoscopic approach to the treatment of mandibular condylar fractures. Surgeons have the opportunity to train and gain surgical endoscopic experience before treating patients.     

Retromandibular approach to condyle fractures: two case reports

Retromandibular approach was first described in 1967 for vertical subcondylar osteotomy and later became popular for surgical treatment of temporomandibular joint dysfunction and low condyle fractures. The trajectory of the incision, parallel to the posterior border of the mandibular ramus, allows a good approach with easy separation of the buccal and marginal mandibular branches of the facial nerve, when they are present in the surgical field. When open reduction and internal rigid fixation with plates and screws are indicated for condylar fractures, retromandibular approach offers an excellent esthetic result with low morbidity. Two clinical cases are presented, in which the surgical treatment was carried out for condylar fractures, and clearly illustrate the proposed approach.     

A protocol for the treatment of mandibular condylar fractures

The authors suggest a protocol for the treatment of mandibular condylar fractures classified by fracture level: the condylar head, the condylar neck and subcondylar fractures. The protocol provides a guide to individualizing intervention according to the type of fracture, the patient's age, the degree of restriction of mandible movement and the possible presence of fractured condyle displacement, which is often associated with functional disorders. The age of the patient is a key factor in the choice of treatment. The therapeutic goal in adult patients differs from that in growing patients, since in children the condyle is a major growth center for the mandible. Management may be surgical or nonsurgical; surgical intervention may be conservative with or without immobilization with closed or open reduction and fixation.     

Surgical complications of mandibular condylar fractures

The purpose of this study was to retrospectively evaluate the complications of 58 patients who underwent surgery for mandibular condylar process fractures. Data were collected from patients during a 10-year period (1999-2009). The data recorded included demographic data, etiology, diagnosis, type of condylar fracture, surgical approaches, and postoperative complications. A total of 58 underwent surgery for reduction of the condylar fractures. There were 22 patients with bilateral condyle fractures and 36 patients with unilateral condyle fractures, accounting for 65 surgeries. In 8 fractures, a preauricular approach was performed to access the fractures condyle, whereas the retromandibular approach was performed in 57 fractures. There were 2 temporary facial palsies, 1 permanent facial palsy, and 1 sialocele. There were no cases of hypertrophic scar, Frey syndrome, or salivary fistula. In conclusion, permanent deformities after surgical complications were unusual, and the results are acceptably safe.     

Open versus closed reduction: diacapitular fractures of the mandibular condyle

Purpose

The purpose of the study was to review the literature regarding the evolution of current thoughts on management of diacapitular fractures (DFs) of the mandibular condyle.

Methods

An electronic search in PubMed was undertaken in March 2012. The titles and abstracts from these results were read to identify studies within the selection criteria. Eligibility criteria included studies reporting clinical series of DFs, including both animal and human studies, without date or language restrictions.

Results

The search strategy initially yielded 108 references. Twenty-eight studies were identified without repetition within the selection criteria. Additional hand-searching of the reference lists of selected studies yielded three additional papers.

Conclusions

The current indications for open reduction and internal fixation (ORIF) of DFs described in the literature are: (a) fractures affecting the lateral condyle with reduction of mandibular height; (b) fractures in which the proximal fragment dislocates laterally out of the glenoid fossa, which cannot be reduced by closed or open treatment of another part of the mandibular fracture. The indications for conservative treatment are: (a) fractures that do not shorten the condylar height (a fracture with displacement of the medial parts of the condyle); (b) undisplaced fractures; (c) comminution of the condylar head, when the bony fragments are too small for stable fixation; and (d) fractures in children. As the temporomandibular joint disk plays an important role as a barrier preventing ankylosis, it is important to reposition the disk (if displaced/dislocated) during the surgical treatment of DFs. The lateral pterygoid muscle should never be stripped from the medially displaced fragment because its desinsertion disrupts circulation to the medial bony fragment, and also because this muscle helps to restore the muscle function after surgery. ORIF of selected DFs improves prognosis by anatomical bone and soft tissue recovery when combined with physical therapy. If conducted properly, surgical treatment of DFs is a safe and predictable procedure and yields good results.     

下颌髁突矢状骨折髓内髓外双重内固定术的临床应用

目的探讨髓内及髓外双重内固定在下颌髁突矢状骨折开放复位内固定中的应用价值。方法采用髓内髓外双重内固定术治疗18例24侧髁突矢状骨折,固定方法：单一螺钉或克氏针行髓内固定,配合一块钛板行髓外固定,伴发他处骨折者同期行精确复位固定。术后通过拍摄CT和全景X线片评价钛板固定情况、骨折段复位精准度及稳固性,通过临床检查评价咬合关系、开口度、开口型。结果术后X线全景片或CT检查显示,24侧髁突矢状骨折段均未发现术后旋转移位,对位良好;钛板和螺钉无扭曲、折断和松脱。术后咬合关系、开口度、开口型恢复良好。结论髓内髓外双重内固定具有抗骨折段旋转作用,髓内螺钉和髓外钛板在空间上互不干扰,是下颌骨髁突矢状骨折固定的良好方法。     

Does lag screw fixation of condylar fractures result in adequate stability? A finite element analysis

The great incidence and controversies related to the diagnosis, treatment, surgical accesses, and type of osteosynthesis materials confer an outstanding role to condylar fractures among facial fractures. Plate configurations, with diverse formats and sizes, may be used to surgically resolve condylar fractures. With the purpose of improving the advantages and minimizing the disadvantages of fixation techniques, the neck screw was developed aiming at the needed stabilization to render a correct fixation through a system of dynamic compression. This is achieved by increasing the contact between the fractured bone stumps, as well as assisting at the time of fracture reduction. The present paper aims at comparing the fixation and stability of mandibular condylar fractures using the neck screw and an overlaid “L”-shaped-4-hole-2 mm plate on the one hand, with a system in which the neck screw and the “L”-shaped plate form a single structure, having been joined by a welded point, on the other hand. The results with the neck screw are satisfactory, and, thus, it is an alternative for the reduction and fixation of fractures of the mandibular condyle, whether or not a plate is joined to the structure, provided it is correctly prescribed and with adequate surgical sequence and technique.     

Transoral resection of a condylar osteochondroma: report of case.

A rare case of osteochondroma (osteocartilaginous exostosis) of the mandibular condyle is described; this represents the seventh documented case in the English language literature. Treatment consisted of transoral surgical resection which maintained condylar integrity. No maxillomandibular fixation was placed and the patient's mandibular function was undisturbed. Postoperatively, mandibular deviation was minimal.     

Fractures of the condylar process

Fractures of the mandibular condyle are frequently seen. There is no consensus on the most appropriate treatment modality. Closed reduction with help of arch bars and guiding elastics is in most cases sufficient. Open reduction and fixation with a plate osteosynthesis or a specially designed lag screw is occasionally performed. Intracapsular fractures of the condylar head are only operated in case of severely reduced mobility, or ankylosis. Fractures of the mandibular condyle normally heal uneventfully. Complications mostly occur in bilateral condylar neck fractures, or intracapsular fractures.