成人下颌骨髁突骨折的手术治疗

对成人髁突骨折采用手术与非手术治疗,学术界一直存在着不同程度的分歧。随着各种小型接骨板、坚强内固定技术的成熟应用,许多学者主张对成人双侧髁突颈部以下脱位性骨折,双侧髁突矢状外脱位性骨折,单侧髁突颈部以下脱位性、移位性骨折行积极外科手术治疗。对髁突骨折患者行外科手术、坚强内固定治疗,可以保证骨折固定具备坚固性和稳定性,并尽早行使功能。本文对髁突骨折外科手术治疗的固定方式、手术入路(耳前入路、下颌下入路、颌后入路、除皱手术入路和近年来报道增多的内窥镜辅助下口内入路)的选择进行了阐述。     

Surgical treatment of fractures of the mandibular condyle: a comparison of long-term results following different approaches - functional, axiographical, and radiological findings.

AIM: While functionally stable osteosynthesis is a generally accepted method to treat all dislocated fractures of the skull, open reduction and rigid fixation of fractures of the mandibular condyle are still controversial. The risks involved in the surgical approaches and the difficulties during reposition are the main controversies. Improvements made in surgical access and osteosynthesis materials as well as the development of special instruments were the reasons for re-evaluating the surgical results. METHODS: Forty patients with displaced or dislocated fractures of the mandibular condyle were re-examined. In 20 patients (21 fractures) an intraoral approach, in 20 more patients (24 fractures) an extraoral perimandibular approach was applied. The results were compared by means of axiography and radiology as well as clinically with regard to function 6 months postoperatively. RESULTS: While almost all fractures were correctly reduced following application of an extraoral access, reduction was correct in only 50% of the patients treated with an intraoral approach. Re-displacement and complications during osteosynthesis were the reasons. The group of patients treated via the intraoral approach showed less favourable results radiologically, clinically, and as judged by the patients' subjective feelings. Especially axiographical examination of the latter fractures revealed a restricted translation indicating that the fractures had not healed primarily. CONCLUSION: In order to avoid complications, the only fractures which should be treated intraorally are those which allow exact reduction even under the conditions of a limited view and reduced possibilities of surgical manipulation during reduction. This applies in general to fractures of the mandibular condyle with a laterally displaced condyle and a shortened ascending ramus. For all other dislocated or displaced fractures, extraoral reduction and osteosynthesis are the methods of choice.     

Plate osteosynthesis of condylar fractures: a retrospective study of 45 patients.

OBJECTIVE: This retrospective study presents the type of osteosynthesis used for the fixation of condylar fractures and the postoperative results and complications observed. METHOD AND MATERIALS: Forty-five patients with fractures of the mandibular condyle underwent open reduction and osteosynthesis with plates and screws. The surgical approach was, in most cases, via a submandibular incision. Stabilization was achieved in the majority of the cases with a 2.0-mm single or double miniplate, but 2.0-mm mini dynamic compression plates were also used. RESULTS: The complications were mainly inadequate reduction, screw loosening, and limitation of mouth opening. No plate fractures or infections were observed. CONCLUSION: The use of a single plate (miniplate or dynamic compression plate) often produces inadequate stability and reduction postoperatively. The placement of two 2.0-mm zygomatic dynamic compression plates demands great tissue dissection and detachment and can lead to limitation of mouth opening. The use of two 2.0-mm miniplates seems to produce better stability and fewer complications.     

Finite element evaluation of three methods of stable fixation of condyle base fractures

The surgical treatment of mandibular condyle fractures currently offers several possibilities for stable internal fixation. In this study, a finite element model evaluation was performed of three different methods for osteosynthesis of low subcondylar fractures: (1) two four-hole straight plates, (2) one seven-hole lambda plate, and (3) one four-hole trapezoidal plate. The finite element model evaluation considered a load applied to the first molar on the contralateral side to the fracture. Results showed that, although the three methods are capable of withstanding functional loading, the lambda plate displayed a more homogeneous stress distribution for both osteosynthesis material and bone and may be a better method when single-plate fixation is the option.     

Axial 'anchor' screw (lag screw with biconcave washer) or 'slanted-screw' plate for osteosynthesis of fractures of the mandibular condylar process.

Almost a quarter of all mandibular fractures are located in the condylar neck region and generally lead to disturbances of occlusion. Because they still possess active growth centres, children and adolescents can take advantage of the joint's remodelling capacity following conservative treatment of these fractures. Fractures with displacement of the condylar head in adults can interfere with function if they are not surgically reduced (Krenkel and Strobl, 1989). In addition, a compensatory overloading of the non-fractured side, which originally goes unnoticed, can bring about disc pathology and chronic pain years later. For this reason, a surgical technique was developed for the management of mandibular condylar neck fractures. A new axial/oblique-axial lag screw (anchor screw) with biconcave washers (anchor washer) makes it possible to carry out standardized osteosynthesis in the region of the thin mandibular condyle neck. Functional exercises can be initiated immediately after the operation. There are three operative procedures using an extraoral approach (1-3) and two using an intraoral approach (4-5), depending on the type and severity of the fracture: 1. Direct anchor screw osteosynthesis with closed gliding hole. 2. Indirect anchor screw osteosynthesis with open gliding groove and safety plates. 3. Osteosynthesis with a 'slanted-screw' plate for longer oblique fractures. 4. Intraoral anchor screw method. 5. Intraoral anchor screw method with intraoral 'slanted-screw' plate. The functional long-term results of conservatively and surgically treated mandibular condylar neck fractures were objectively documented by means of mechanical and electronic axiography. The functional long-term results of the condylar neck fractures treated surgically were significantly better than those treated conservatively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Fixation of comminuted diacapitular fractures of the mandibular condyle with ultrasound-activated resorbable pins

We describe the fixation of bilateral comminuted diacapitular fractures of the mandibular condyle with ultrasound activated resorbable pins (KLS Martin SonicWeld Rx) by an open approach with primary fixation of the fractures using the resorbable osteosynthesis pins.     

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.     

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.     

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.     

Treatment and complications of mandibular fractures: A 10-year analysis

The surgical treatment and complications of patients with mandibular fractures in Amsterdam over a period of 10 years are analysed. Between January 2000 and January 2009 225 patients were surgically treated for a mandibular fracture (mean age of 32.6 (SD ± 14.6) years). A total of 426 fracture lines were identified. Of 213 dentate patients 29 patients were treated primarily with intermaxillary fixation (IMF). IMF combined with osteosynthesis was performed on 99 patients. Seventy-nine patients received IMF only per-operatively to make open reduction and internal fixation (ORIF) possible. Of 12 edentulous patients three patients were treated with Gunning splints. Nine patients were treated by manual reduction and internal fixation. A total of 1965 screws and 442 plates were used. Sixty (26.7%) patients presented with complications, including (transient) hyposensibility of the lip and chin (34 patients), dysocclusion (15 patients), infected osteosynthesis material (six patients) and temporomandibular dysfunction (five patients). Four patients needed surgical retreatment for correction of a dysocclusion. The results of this report are partly in line with other studies and provide important data for improving the treatment of the fractured mandible.     

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.     

口腔内入路行髁突高位骨折复位固定的临床治疗

目的:探讨应用定量截骨锯,行口腔内入路髁突高位骨折手术治疗的效果。方法:对13例14侧下颌骨髁突颈骨折患者采用口腔内入路,用定量截骨锯将下颌骨升支后缘垂直截骨,取出升支后缘骨块,将骨折的髁突游离后取出,体外直视下将骨折片与升支后缘骨块复位固定后再从口腔内原切口回植,行颞下颌关节重建。结果:术后6、12、24月复查全部患者的开口范围25～40mm,平均为37.2mm。除1例患侧后牙早接触,下切牙中线偏斜1mm;另1例张口约25mm,轻度受限外,其余患者咬合关系良好,无其他并发症。结论:口腔内入路具有无外部皮肤瘢痕,且不损伤面神经的优点。但操作视野较小,增加了操作的难度。     

The results of the surgical treatment of fractures of the mandibular condyle in children]

The results of surgical treatment of fractures of the mandibular condyle are analyzed in 36 children (39 surgeries) aged 3 to 17; 33 of the operations were carried out in fractures complicated with the dislocation of the condylar head. Reposition and osteosynthesis of the fragments were carried out in 17 cases, replantation of the condyle in 10, and arthroplasty of the temporomandibular joint in 12 patients. Good late anatomico-functional and esthetic results were achieved in 84.6% of cases; this is explained by a differentiated approach to the choice of surgical strategy, an effective system of rehabilitation measures, including early exercise, orthodontic treatment, and low-frequency electromyostimulation.     

Complications in endoscopic-assisted open reduction and internal fixation of mandibular condyle fractures

Endoscopic-assisted open reduction and internal fixation (EAORIF) of subcondylar fractures is minimally invasive, provides excellent visibility without a large incision, and reduces surgical scarring and the risk of facial nerve injury. This study evaluated the complications associated with EAORIF. Twenty-six patients underwent EAORIF for mandibular condyle fractures. The postoperative follow-up period was longer than 6 months. We analyzed associations between the complication incidence and the number of fixation plates, accompanying mandibular fractures, and age. Eighteen (69.2%) and 6 (23.1%) patients had temporary (<3 months after surgery) and long-term (>6 months after surgery) complications, respectively. Patients older than 30 years had complications more frequently than those younger than 30 years. Complication rates were similar for different numbers of fixation plates and among patients with and without accompanying mandibular fractures. EAORIF is a reliable technique for treating condylar fractures, regardless of patient age, number of fixation plates, or accompanying mandibular fractures. However, improvements are needed to reduce long-term complications.     

下颌骨髁突骨折术后并发症的临床研究

目的:探讨手术治疗髁突骨折与并发症发生的关系及预防措施。方法:回顾分析采用手术治疗的116例(146侧)髁突骨折病例的临床资料,以开口度、开口型、咬合关系、咀嚼功能、面神经损伤和术后瘢痕等作为术后评价标准;对患者的术前、术后、以及随访的影像片进行数字化分析.随访时间3个月~20年。结果:116例髁突骨折病人中,采取切开复位坚强内固定术86例和髁突摘除术30例。手术开放复位坚强内固定(ORIF)的研究组中,手术进路及固定方式与并发症的发生关系密切,这些并发症包括颞下颌关节紊乱病,下颌偏斜,面神经损伤,术后瘢痕,以及咬合关系紊乱,张口受限甚至关节强直等。结论:根据髁突骨折的分型选择正确的手术方法;髁突骨折手术切开复位坚强内固定效果较好,但不同类型的髁突骨折应选用不同的手术进路及合适的复位固定方法,以最大限度地预防及减少术后并发症的发生。     

Mandibular osteosynthesis by miniature screwed plates via a buccal approach.

The modified Michelet's (1973) technique of mandibular osteosynthesis, which consists of monocortical juxta-alveolar and sub-apical osteosynthesis, without compression and without inter-maxillary fixation, is described. This technique can be used in many types of mandibular fracture, single or multiple, associated or isolated, except in the case of a fracture of the condylar neck and in the presence of pre-existing infection. Infected fractures are treated by orthopaedic methods. Materials used (plates and screws) and particulars of the method have been tested by multi-disciplinary experimentation, particularly by anatomical verification and biomechanical studies. The ideal line of osteosynthesis is described. For the author, this technique is a routine treatment of any type of mandibular fracture.     

INION compared with titanium osteosynthesis: a prospective investigation of the treatment of mandibular fractures

We prospectively studied two groups of 30 patients to assess the outcome of treatment of mandibular fractures with the biodegradable INION^® system compared with osteosynthesis with titanium miniplates. The degree of occlusion, wound healing, and swelling, were noted preoperatively and at 1 week, 6 weeks, and 6 months postoperatively.All fractures healed uneventfully, both clinically and radiologically, and independently of the osteosynthesis used. We found no long-term disturbance of occlusion, but there were twice as many malocclusions in the INION^® group at one week. We now use a 3–5 day period of postoperative elastic intermaxillary fixation (IMF) to prevent material deformities. Both groups developed problems with wound healing; with INION^® adequate soft tissue closure combined with appropriate positioning of the plates prevented this. At 6 months a dense swelling developed in some patients in the INION^® group as a result of biodegradation of the plates.INION^® plates were biocompatible and strong enough to treat mandibular fractures.     

Axial ‘anchor’ screw (lag screw with biconcave washer) or ‘slanted-screw’ plate for osteosynthesis of fractures of the mandibular condylar process

Almost a quarter of all mandibular fractures are located in the condylar neck region and generally lead to disturbances of occlusion. Because they still possess active growth centres, children and adolescents can take advantage of the joint's remodelling capacity following conservative treatment of these fractures. Fractures with displacement of the condylar head in adults can interfere with function if they are not surgically reduced (Krenkel and Strobl, 1989). In addition, a compensatory overloading of the non-fractured side, which originally goes unnoticed, can bring about disc pathology and chronic pain years later.For this reason, a surgical technique was developed for the management of mandibular condylar neck fractures. A new axial/oblique-axial lag screw (anchor screw) with biconcave washers (anchor washer) makes it possible to carry out standardized osteosynthesis in the region of the thin mandibular condyle neck. Functional exercises can be initiated immediately after the operation.There are three operative procedures using an extraoral approach (1–3) and two using an intraoral approach (4–5), depending on the type and severity of the fracture:

1. Direct anchor screw osteosynthesis with closed gliding hole.

2. Indirect anchor screw osteosynthesis with open gliding groove and safety plates.

3. Osteosynthesis with a ‘slanted-screw’ plate for longer oblique fractures.

4. Intraoral anchor screw method.

5. Intraoral anchor screw method with intraoral ‘slanted-screw’ plate.

The functional long-term results of conservatively and surgically treated mandibular condylar neck fractures were objectively documented by means of mechanical and electronic axiography. The functional long-term results of the condylar neck fractures treated surgically were significantly better than those treated conservatively. The compensatory overload on the non-fractured side in the conservatively treated group, confirmed by axiography, predisposes this joint to disc pathology and secondary joint damage due to overstretching of the capsular ligaments. Therefore, osteosynthesis of condylar neck fractures not only serves to restore anatomical conditions, but also acts as a preventive measure against overloading the non-fractured side.     

Treatment of mandibular-condylar fractures

Particularly with true dislocation fractures, nonoperative treatment with maxillomandibular fixation followed by physiotherapeutic exercises leads to poor results, as was proved with axiography and clinical examinations. The main reason for this is the shortening and scarring of the condyloid process and the lack of function of the lateral pterygoid muscle. The condyle with its insertion of the muscle is usually displaced medially and anterially and nearly in touch with the origin on the pterygoid process so that protrusion by the muscle is no longer possible. The physiologic relationship of the lateral pterygoid muscle is restored after reduction of the condyle and osteosynthesis of the condylar neck fracture and the original distance between origin and insertion of the muscle is re-established and is a fundamental necessity for regaining function (Fig. 40). The anchor screw osteosynthesis is a most effective technique with low limitations for its indication. A comparison with plates shows this technique to be very economic because one anchor screw has the effect of at least one five-hole plate with five plating screws. That means a reduction of osteosynthesis implants of up to 80%, which saves a lot of money. On the other hand, the sophisticated technique of an anchor screw osteosynthesis needs some training on the part of the surgeon to get the best results possible. In general, we could realize that the anchor screw osteosynthesis gives a perfect adaptation of the fracture ends with compression also on the inner cortical layer, which with plates is only possible in rare cases. After an osteosynthesis of mandibular condyle neck fractures with an axial anchor-screw there are a few cases with an absorptive process in the fracture interface where the screw migrates in an axial direction with loosening of the osteosynthesis. This effect can be compared with the effect of a dynamic hip screw, which leads to compression of the callus, which speeds up bony union at the expense of shortening the bone. When the same absorption happens using a plate, the fracture ends cannot become sintered and the plate is in danger of fracturing as a result of metal fatigue. Ceipek evaluated 136 patients with mandibular condylar neck fractures treated with axial anchor screw osteosynthesis. Thirty-six of these screws showed signs of migration, but only 3.7% for more than 4 mm. For the migration process there are some important risk factors: difficult repositioning of the proximal fragment, dorsal luxation fracture, indirect method of anchor screw osteosynthesis, narrow condyle neck, no intercuspation in the molar region, no compliance, and disturbance of bone healing. Another stable technique of osteosynthesis should be used if patients show more risk than one risk factor.     

Endoscopic mandibular condyle fracture repair

Treatment of mandibular condyle fractures remains a controversial issue. Arguments center on the relative merits of open versus closed treatment. In the past decisions were largely based on philosophy, anecdotal experience, and retrospective case series with short follow-up. Well-designed studies have now begun to appear in the literature and suggest improved results after open, anatomic reduction and fixation. Many surgeons are still hesitant about liberally applying the open approach due to the resultant facial scarring and the risk of facial nerve injury. Developments in endoscopic technology have recently been applied to facial fracture repair. The endoscopic approach to mandibular condyle fracture repair reduces the risk of facial nerve injury, and dramatically reduces facial scarring, compared with standard open approaches. We feel that the reduced morbidity of the endoscopic approach may allow the benefits of anatomic reduction and rigid fixation to be offered to a larger proportion of patients with mandibular condyle fractures. Technical and technological advances are expected to aid in the dispersal of these techniques in the future.