Extraoral approach to mandibular condylar fractures: Our experience with 100 cases

IntroductionMandibular condylar fractures are very common. The current literature contains many indications and methods of treatment. Extraoral approaches are complicated by the need to avoid injury to the facial nerve. On the other hand intraoral approaches can make fracture reduction and/or fixation difficult. The mini-retromandibular approach provides an excellent view of the surgical field, minimises the risk of injury to the facial nerve, and allows rapid and easy management of condylar fractures.We have collected and reviewed our first 100 condylar fractures treated by means of a mini-retromandibular approach.Patients and methodsBetween June 2006 and June 2012, Eighty-seven patients with extracapsular condylar fractures underwent open reduction and rigid fixation for 100 extracapsular condylar fractures via a mini-retromandibular approach.ResultsDental occlusion and anatomic reduction were restored in all 100 condylar fractures. Postoperative infection developed in three patients. There was one sialocele and one case of plate fracture. Four patients experienced transient palsy of the buccal branch of the facial nerve. No permanent deficit of any facial nerve branch was observed.No patient showed condylar head resorption.ConclusionsOur experience with the treatment of the first 100 condylar fractures using the mini-retromandibular approach has demonstrated that this technique has allowed the Authors to safely manage extracapsular condylar fractures at all levels.     

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.     

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...     

Role of surgical reduction of condylar fractures in the management of panfacial fractures

We present nine panfacial fractures that were treated during a two-year period in which the first step in treatment was reduction of condylar fractures. There was no evidence of dental or skeletal alterations and measurement of the mandibular ramus and radiographic examination show that posterior facial height as well as projection and width of the inferior lower third of the face, was restored. The correct timing of surgical intervention and the use of rigid fixation allows the restoration of the morphological and functional nature of the face after panfacial fractures.     

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.     

髁突骨折手术治疗的临床研究

目的：探讨手术治疗髁突骨折的适应证、技术要点和并发症的发生因素。方法：回顾分析5年来采用手术治疗的116例髁突骨折病例的临床资料,分别采取切开复位内固定术和髁突摘除术,随访3个月至3年,复查内容包括患者咬合关系、开口度、开口型、神经损伤、颞下颌关节症状、面型和X线检查。结果：外形和功能均显著恢复,113例咬合关系恢复正常,占97.4%;115例张口度恢复正常,占99.1%;X线复查髁突骨折解剖复位率94.8%;15例儿童患者恢复良好,无下颌骨发育障碍等严重并发症发生。结论：坚强内固定技术是治疗髁突骨折的较好方法,严重移位或脱位的儿童髁颈和髁颈下骨折应采用可吸收接骨板进行内固定。     

下颌骨髁突骨折手术治疗的发展与现状

下颌骨髁突骨折的治疗一直存在着广泛的争议。近年来随着研究的深入和内固定技术的不断进步,手术治疗的适应证范围在不断扩大,疗效在不断提高,并发症的发生率也在不断降低;手术治疗越来越引起重视,传统的闭合性治疗受到了越来越严峻的挑战。下颌骨髁突骨折的手术需要遵循3个原则:即正确的解剖复位,可靠的固定和最小的损伤。作者就髁突骨折的分类、手术适应证、手术进路、固定方法以及术中术后的若干问题等作一综述。     

内镜技术在髁突骨折治疗中的应用

内镜技术作为实现外科微创化的重要手段,已逐步开始应用于口腔颌面外科领域。内镜辅助经口内入路的髁突骨折复位与固定可以避免面部产生明显可见的瘢痕,并降低面神经损伤的风险。合理地选择适应证,临床医生经过足够的训练,内镜技术可以作为髁突骨折治疗的理想选择。     

Transmasseteric antero-parotid approach for open reduction and internal fixation of condylar fractures

The morbidity that results from surgical approaches to the condylar neck, and the time-consuming nature of the operation inhibits many surgeons from using open reduction and internal fixation for the treatment of condylar fractures. The many approaches that have been described stand testimony to the disadvantages of the individual techniques. The most common problems are limited access and injury to the facial nerve. We describe the transmasseteric antero-parotid (TMAP) technique, which offers swift access to the condylar neck while substantially reducing the risk to the facial nerve and eliminating the complications associated with transparotid approaches.     

�ھ���������ͻ���������е�Ӧ��

??Abstract??Endoscopic-assisted technique could make surgery more minimally invasive?? and has been applied in the field of oral and maxillofacial surgery in recent years. In condylar fractures?? the endoscope may be used to restore preinjury condylar height and angulation?? avoiding the feared risks of facial nerve injury and visible scarring. When used selectively?? endoscope-assisted open reduction and internal fixation would be one of the best choices for the management of condylar fracture.     

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。     

Splint-assisted reduction of comminuted or complex maxillofacial fractures

The aim of the study was to obtain anatomic bone healing and restoration of the patient's premorbid occlusion in complex facial fractures or comminuted facial fracture. Ten patients who applied to a tertiary health care clinic with complex or comminuted fractures, and mandibular fractures combined with condylar fractures which may impair the occlusal harmony were included in the study.After the preparation of premorbid occlusal splints and direct bonded orthodontic brackets, splint-assisted reduction and internal fixation have been performed. The treatment protocol was completed with 4 to 6 weeks of intermaxillary fixation over the splint. All fracture lines showed complete bone healing, without major complications requiring further treatment. Complications included a minor degree of malocclusion in one of the panfacial fracture patients and slight avascular resorption of the condyle in one of the avulsive open comminuted mandibular fracture patients.Using orthodontic splints and direct bonded brackets to obtain and maintain delicate reduction is an efficacious method for the prevention of occlusal disharmony and aesthetic impairments in comminuted lower facial unit and complicated facial fracture patients.     

翼外肌-髁突解剖复位内固定治疗髁突颈骨折60例的临床分析

目的 探讨髁突颈部骨折时进行髁突-翼外肌解剖复位坚强内固定的适应证、手术方法 及术后效果。方法 对髁突颈部骨折出现髁头脱位突破关节囊、髁突和髁突颈下骨折移位成角大于30°~45°、下颌支垂直高度降低超过4~5 mm的骨折患者,采用耳屏前绕耳轮脚向上后耳颅沟切口,行翼外肌-髁突肌解剖复位坚强内固定方法 治疗。术后1、3、6个月复诊,检查面型、开口度、开口型、牙合关系、咀嚼力、面神经功能,三维CT重建上下颌骨,根据临床和影像学进行评价。结果 术后1月,所有患者面型对称、牙合关系好、开口度均较术前增大;无骨折移位、患侧咀嚼力减弱、8例额纹变浅。3月后,所有病例面型对称、开口度≥3.5 cm、开口型无偏斜、骨折一期愈合、髁突表面未见骨质吸收、面神经瘫痪症状恢复、双侧咬合力对称。6月后观察所有项目同术后3月。结论 髁突骨折经耳屏前后上绕耳轮脚切口,能较好的保护颞下颌关节区相关血管神经;对髁突颈部骨折行翼外肌-髁突解剖结构开放性复位内固定,是一种恢复解剖形态和关节功能的有效方法 ,在术后3月内可判定其效果。     

耳前角形切口在髁突骨折切开复位内固定术中的应用

目的:探讨应用耳前角形切口在髁突骨折切开复位内固定术中的应用效果。方法:对78例100侧下颌骨髁突骨折患者采用耳前角形切口术区皮下行肿胀液注射后沿皮下翻瓣在颧弓上方2 cm切开颞深筋膜浅层并沿此层深面剥离到颧弓,分离显露骨折部位,直视下行髁突骨折解剖复位内固定术。结果:术后通过临床及影像学检查随访,效果满意,无严重并发症。结论:耳前角形切口结合皮下肿胀分离技术可为髁突骨折切开复位内固定术提供良好的视野,方便骨折复位固定,安全便捷,值得临床推广。     

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。     

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。     

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.     

Fractures of the mandibular condyle: a review of 466 cases. Literature review, reflections on treatment and proposals.

INTRODUCTION: The incidence of condylar fractures is high. Condylar fractures can be extracapsular (condylar neck or subcondylar) or intracapsular, undisplaced, deviated, displaced or dislocated. Treatment depends on the age of the patient, the co-existence of other mandibular or maxillary fractures, whether the condylar fracture is unilateral or bilateral, the level and displacement of the fracture, the state of dentition and the dental occlusion, and the surgeon's experience. PURPOSE: This report presents the experience acquired in the treatment of 466 condylar fractures over 7 years, reviews the pertinent literature and proposes guidelines for treatment. MATERIAL AND METHODS: The archives of KAT, General District Hospital between 1995 and 2002 were scrutinized and the condylar fractures were recorded. The aetiology, age, sex, level of fracture, degree of displacement, associated facial fractures, malocclusion, and type of treatment were noted. RESULTS: Four hundred and sixty-six condylar fractures were admitted, the male:female ratio was 3.5:1. Road traffic accidents were the main cause and most fractures were unilateral, displaced, subcondylar, occurred on the left side and were treated conservatively. CONCLUSIONS: Early mobilization is the key in treating condylar fractures. Whilst rigid internal fixation provides stabilization and allows early mobilization, conservative treatment is the treatment of choice for the majority of fractures. Children and intracapsular fractures are treated conservatively with or without maxillo-mandibular fixation. Open reduction is recommended in selected cases to restore the occlusion, in severely displaced and dislocated fractures, in cases of loss of ramus height, and in edentulous patients. It may be considered in those with 'medical problems' where intermaxillary fixation is not recommended.     

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.     

改良耳屏切口应用于髁突骨折切开复位内固定术的临床观察

目的探讨改良耳屏切口在髁突骨折切开复位内固定术应用的效果。方法 16例髁突骨折患者经改良耳屏切口行髁突骨折切开复位内固定术。方法为沿耳屏切开,在外耳道和腮腺后缘间钝性分离,注意保护耳屏处软骨,把腮腺组织向前牵开,这样能把面神经完整地推向前方,不必专门解剖面神经。直视下觅得两骨折段,按原位置和方向复位,以小型钛板坚固内固定。术后半年复诊。结果 16例病例术后伤口均Ⅰ期愈合,咬合关系恢复良好,面部形态满意。术后半个月张口度大于3.0 cm,半个月及半年后X线片检查,髁突复位良好,无骨折部位不愈或延迟愈合表现,无内固定物松脱,愈合后瘢痕隐蔽,美观效果好,均无面神经损伤症状,临床疗效满意。结论改良耳屏切口在髁突骨折切开复位内固定术的应用中,由于其切口隐蔽安全,利于保护面神经及重要血管,减少并发症,是一种恢复解剖形态和关节功能的有效方法。