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.     

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.     

下颌下小切口入路行髁突颈部骨折复位固定术的疗效观察

目的：观察下颌下小切口入路用于髁突颈部骨折复位固定的疗效。方法：纳入研究病例26例,术前确诊为髁突颈部骨折并且具备手术适应证。于下颌角位置做小切口,分离并保护面神经下颌缘支,于该神经上横断咬肌后1/3,骨折断端暴露后,解剖复位并钛板固定。结果：26例患者均恢复正常咬合关系,开口度和开口型均正常,面部对称,无面神经损伤。结论：下颌下小切口入路利用面神经下颌缘支和下颊支之间的解剖间隙,在髁突颈部骨折治疗中效果良好。     

经咬肌颌后入路治疗髁突中低位骨折

目的 探讨下颌骨髁突中低位骨折内固定术新入路的方法 及治疗效果.方法 对16例单侧髁突中低位骨折患者沿下颌后作2 cm小切口,顺表浅肌肉腱膜系统(SMAS)表面向前方分离,确认骨折线后钝性分离SMAS,避开腮腺,于咬肌内平行咬肌肌束钝性分离暴露骨折线后,直视下对髁突骨折端进行复位固定.结果 所有患者复位满意,咬合关系良...     

内镜辅助髁突下骨折的复位与内固定

目的：为减少明显的瘢痕和面神经损伤的机会,采用内镜辅助经口内入路进行成年人髁突下骨折的复位与固定。方法：从2003年4月—2005年12月就诊的11例髁突下骨折病例,全麻下口内切开,内镜辅助下进行髁突下骨折的复位与内固定,同期行其他部位骨折的复位与固定。结果：11例患者中有9例获得了良好的解剖复位,另2例因存在骨质缺损未能达到精确的解剖复位。手术后恢复较快,均无面神经损伤症状。随访期为1.5～3.8a,平均2.2a。术后6个月内关节功能正常,瘢痕不明显;随访期末,平均开口度为3.6cm,2例患者出现关节弹响,但不影响生活。结论：经口内入路内镜辅助的下颌骨髁突下骨折复位与固定可达到开放性手术类似的疗效,并可减少瘢痕的形成和面神经损伤的发生。     

腮腺前缘咬肌入路固定髁状突中低位骨折

目的：探讨腮腺前缘咬肌表面面神经间入路复位固定下颌骨髁突中低位骨折的方法。方法：37例43侧髁突中低位骨折患者随机分为两组,A组：16例19侧耳前切口穿腮腺入路复位固定骨折;B组：21例24侧髁状突中低位骨折患者采用绕下颌角皮肤切口,腮腺前缘、咬肌表面面神经间入路,直视下复位固定骨折。对两组的临床疗效进行比较。结果：B组术后第2d咬合关系恢复情况,涎瘘发生情况及术后1月下颌运动时关节局部牵拉不适感等方面均优于A组,差异有统计学意义（P＜0．05）;面神经功能障碍、术后CT三维重建骨折断端对位及术后1月患者主观满意度等方面差异无统计学意义（P＞0．05）。结论：腮腺前缘、咬肌表面面神经间入路可获得较为理想的术野,直视下保护面神经、复位固定骨折,不需分离腮腺,发生涎瘘和面神经损伤的危险性大大降低,并能用于下颌支粉碎性骨折等较为复杂的骨折的治疗,是安全有效的手术路径之一。     

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.     

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。     

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.     

Surgical treatment of mandibular condylar fracture by direct approach to reach the facial nerve

Surgical treatment of 10 condyles of 8 patients with mandibular condylar fracture by direct approach to reach the facial nerve was retrospectively discussed. In three lower condylar fractures, open reduction and fixation by means of a mini-plate system were perfomed under direct vision and resulted in successful clinical outcomes. In 7 upper condylar fractures, condylar segments were removed because they were not able to reduce and fix. Postoperatively, temporal facial paralysis of tomporal or zygomatic branches occured at five operated sites and completely recovered two to four months. We recognized that this approach, which can make a broad exposure and a wide operative fieled, is very suitable for lower and upper condylar fracture.

     

Dislocated pediatric condyle fractures — should conservative treatment always be the rule?

AimThe results of conservative treatment of pediatric dislocated (luxative) condyle fractures are usually unsatisfactory. We therefore decided to present and analyze the results of surgical treatment of these fractures.Patients and methodsChildren with dislocated condyle fractures were treated surgically, with the approach always including opening the temporomandibular joint (TMJ).Postoperatively, patients had regular controls at 1 week, 1 month, 3 months, and 6 months, and then yearly thereafter. At each control visit, facial symmetry, maximal mouth opening, lateral chin deflection upon mouth opening, TMJ pain, condylar motion, palpable pathological phenomena, and occlusion were all checked clinically. Healing of the fracture site, condylar height, shape and growth were assessed on panoramic radiographs. Possible surgical complications were noted: temporary facial nerve palsy, development of a parotid salivary fistula, disturbance of auricle sensibility due to injury of the greater auricular nerve, miniplate fracture, intraoperative bleeding, postoperative hematoma formation, infection, and reoperation due to fragment malposition. The postoperative scars were assessed.ResultsOver the 6-year period from 2013 until the end of 2018, seven children with dislocated condyle fractures were treated surgically. Six of the seven patients were treated with open reduction and internal fixation, and the plates and screws were deliberately not removed. The age range of the patients was 1.5–14 years (average 6.1 years). Follow-up time was 15 months to 6 years. No growth disturbances or facial asymmetries were seen over this follow-up period, with all patients maintaining proper occlusion, joint movement, and mouth opening. Fracture healing and condylar growth were clearly demonstrated with serial control panoramic radiographs. Condylar height asymmetry was observed only in one case, in which only reduction of the fracture with no fixation was performed. In all other cases, condylar height was symmetric. None of the children presented with chewing difficulties or joint pain. No intra- or postoperative surgical complications were noted. The preauricular scars were all very discreet, and none of the patients or parents complained about them.ConclusionSurgical treatment in cases of dislocated (luxative) condylar fractures in children and small infants restores anatomy and thus securely enables further symmetric growth of the condyles, mandible, and the entire facial skeleton.     

Open Reduction and Rigid Internal Fixation of Mandibular Condylar Fractures by an Intraoral Approach: A Long-Term Follow-Up Study of 15 Patients

PURPOSE: To evaluate the long-term results obtained with open reduction and rigid internal fixation of mandibular condylar fractures by an intraoral approach. PATIENTS AND METHODS: Fifteen patients with 24 mandibular condylar fractures were retrospectively examined with an average follow-up of 23 months (range, 6-63 months). Clinical and radiographic examination was conducted according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), including an evaluation of maximum voluntary bite force measurements and facial nerve function. Statistical analysis was performed on maximum voluntary bite force measurements and maximum pressure pain threshold. RESULTS: Two patients fulfilled the criteria for a RDC/TMD diagnosis. Myofacial pain (group I) and bilateral arthralgia (group III), combined with a moderate nonspecific physical symptom score, was diagnosed in 1 patient and 1 patient received a diagnosis of disc displacement with reduction (group II). Satisfying radiographic fracture healing was seen in 12 joints. However, miniplate fracture occurred in 3 patients and severe bone resorption of the condylar head was seen in one patient. Minor adjustment of the postoperative occlusion was necessary in 6 patients. No significant difference between maximum voluntary isometric bite force measurements or maximum pressure pain threshold was found between the fracture side and the opposite side in unilateral cases or between the operated and nonoperated side in bilateral cases. None of the patients showed facial nerve injury or visible facial scars. CONCLUSION: Within the limitations of a retrospective study, the present study emphasized that optimal management of dislocated bilateral condylar injuries combined with other fractures of the facial skeleton constitute a challenging issue in maxillofacial trauma. Moreover, open reduction and rigid internal fixation of mandibular condylar fractures by an intraoral approach is a technically demanding surgical procedure associated with a high risk of postoperative complications in these injuries.     

低位髁状突骨折的手术探讨

目的：探讨低位髁状突骨折手术入路和内固定材料的选择。方法：选择25例低位髁状突骨折患者,采用不同手术入路及钛板内固定。结果：全部伤口一期愈合,经观察3~6个月骨折端对合良好,无明显并发症。结论：各种手术入路均有其优缺点,解剖面神经入路,尤其对斜线型低位骨折效果更佳,小型钛板内固定效果优于微型钛板内固定。     

Use of an occlusal splint and intraoperative imaging with an intraoral approach in the management of mandibular subcondylar fractures

IntroductionTo evaluate the feasibility of safely managing subcondylar fractures using an original surgical procedure combining an intraoral approach, the use of a custom-made occlusal overlay splint, and intraoperative imaging.Materials and methodsCondylar fragment was freed from surrounding soft tissues, was laterally exposed to the ramus, and a miniplate was fixed in place for osteosynthesis. An overlay splint maintaining the dental occlusion was used to facilitate reduction and stabilization during fixation. Intraoperative monitoring by cone-beam computed tomography (CBCT) was performed before completing the fixation.ResultsBetween November 2018 and June 2019, 10 patients were treated using this procedure. The median length of the proximal condylar fragment was 29 mm (range 24–39 min). Five patients had an associated mandibular fracture. The median duration of the condylar fracture surgery was 54.5 min (range 38–79 min). All patients had satisfactory reduction and osteosynthesis with no complications.ConclusionIt is feasible to safely manage subcondylar fractures with this surgical procedure that could facilitate open reduction using intraoral approaches. Occlusal splints maintain downward pressure on the rami bilaterally and symmetrically, helping to anatomically reposition condylar process fractures. Intraoperative imaging is used to monitor this step.     

Does encountering the facial nerve during surgical management of mandibular condylar process fractures increase the risk of facial nerve weakness? A systematic review and meta-regression analysis

Purpose

The purpose of this study was to identify whether the incidence of systematically identified or incidentally encountered facial nerve branches during dissection to approach condylar fractures increases risk of transient and/or permanent facial nerve weakness.

耳周切口治疗髁突颈部骨折

目的:介绍一种新的治疗髁突颈部骨折的手术入路。方法:通过改良的耳周小切口,经腮腺入路,对31例36侧髁突骨折行小型钛板坚强内固定术。术后随访3个月,从患者的开口度、咬合关系、面神经功能和影像学检查等方面进行疗效分析。结果:31例患者中,2例出现暂时性面神经功能不全,所有患者均咬合关系良好,张口度最大者4.8 cm,最小者3.0 cm,平均张口度4.0 cm,无张口偏斜。术后3个月CT显示所有患者髁突均完全解剖复位。结论:较之传统手术切口,改良的腮腺入路切口隐蔽,手术创伤小,利于面神经保护,且能达到髁突骨折解剖复位和坚强内固定的要求。     

A novel ultrasound-guided minimally invasive technique for the treatment of extracapsular condylar fractures

The aim of this study was to present a novel ultrasound-guided minimally invasive technique for the treatment of extracapsular condylar fractures and evaluate its long-term outcomes.Seven patients with isolated extracapsular condylar fractures with a noncomminuted proximal segment were included in this study. Ultrasound was used for identification of the position of the bone segments and intraoperative confirmation of appropriate reduction. Reduction of the displaced segments was performed using threaded K-wires under ultrasonographic visualization. The bone segments were stabilized using an adjustable modified external fixator designed by us, which allows manipulation of the segments in three planes intraoperatively and postoperatively, if needed. The functional outcomes of patients were evaluated. Patients treated with ultrasound-guided percutaneous reduction and external fixation achieved normal occlusion with satisfactory mouth opening (>35 mm) and had no pain during mandibular movements at long-term follow-up. None of the patients had any signs of facial nerve injury.Within the limitations of the study it seems that the poposed approch might be an alternative to the open approach in selected cases.     

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.     

Transoral endoscopic-assisted management of subcondylar fractures in 17 patients: An alternative to open reduction with rigid internal fixation and closed reduction with maxillomandibular fixation

The authors evaluate the results of transoral endoscopic-assisted open reduction and miniplate fixation of subcondylar fractures. Seventeen patients were treated from August 2005 to April 2007. Inclusion criteria were: adult patients, inability to achieve adequate occlusion with closed reduction, dislocation of the condylar fragment between 10 and 45°, and 2-mm inter-fragment overlapping. Regular panoramic radiographs were taken postoperatively. Transbuccal incisions were used to place the screws for fixation in 15 patients. Pure intraoral access and angulated drills and screwdrivers were used in 2 patients. The condyle was placed into the condylar fossa in all cases. No damage to the facial nerve was observed. No visible scars were present. Mean surgical time was 80.36 minutes. Transitory hyposthesia was observed in 3 cases. Adequate reduction and consolidation of the fracture was achieved in 16 patients. No condylar reabsortion was present at the end of the follow-up period. The authors consider that transoral endoscopic-assisted open reduction constitutes a valid alternative to a transcutaneous approach for the reduction and fixation of subcondylar fractures in selected cases. It provides the benefits of open reduction and internal fixation without the potential complications. Advice is given on how to achieve adequate reduction and stability of the proximal fragment.     

Management of Subcondylar Fracture through Intraoral Approach with Rigid Internal Fixation

Background  

In Oral and Maxillofacial Surgery, the majority of the condylar fractures are treated by closed reduction with generally satisfactory long term results. But in such cases of closed reduction, patient will be uncomfortable owing to long term application of inter maxillary fixation (IMF). Where as, Disadvantages of extra oral open reduction and fixation of condylar fracture includes facial nerve damage, facial scars etc. which are surely eliminated by the intraoral reduction and rigid fixation.