Resorption behaviour of the articular surface dome and functional outcome after open reduction and internal fixation of mandibular condylar head fractures using small-fragment positional screws

Purpose

The aim of the study was to evaluate the resorption of the mandibular condylar head after open reduction and internal fixation of fractures with small-fragment screws and to evaluate the functional outcome.

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.     

Finite element analysis of type B condylar head fractures and osteosynthesis using two positional screws

ObjectiveThe aim of this study was to explore the cause of type B condylar head fracture after parasymphyseal impact, and evaluate the biomechanics of osteosynthesis using two positional screws for the repair of this type of fractures.MethodsA finite element model of the mandible was created, and a parasymphyseal impact was simulated using Mimics 10.01 and Abaqus 6.10 software. The type B condylar head fracture was simulated in the right condyle using a mimics simulation cut with polyplane module according to the analyzed results together with clinical experience, and the left condyle was used as a control. Two positional screws were used for rigid internal fixation of the fracture. von Mises stress distributions in the condyles and screws were analyzed.ResultsThe von Mises stress generated in parasymphyseal trauma simulation showed a significant concentration in the sagittal direction of the condyle. In two-positional-screw osteosynthesis of the condylar head fractures, stress concentration appeared within the screws in the gap area between the two fractured segments and the area around the screw head. A small amount of stress was distributed in the screw holes and on the posterior surfaces of both segments. The von Mises stress was negligible in the fractured sagittal surfaces.ConclusionIt is reasonable to attribute the cause of type B condylar head fracture to the anatomical features of the condyle. The biomechanics of two-positional-screw osteosynthesis revealed that the stress can transmit through the screws to the medial fragments, and the stresses on both sagittal fractured surfaces are minimal.     

Condylar remodeling after osteosynthesis of fractures of the condylar head or close to the temporomandibular joint

PurposeCondylar head fractures (CHFs) are increasingly treated by open reduction and internal fixation (ORIF). However, there are no reports on the three-dimensional postoperative volumetric transformation of the condyle, especially with regard to fragmented cases. Protruding hardware can lead to severe complications, so the goal of this study was to examine the amount of condylar bony resorption occurring after ORIF.MethodsIncluded were surgically treated CHFs with eligible cone beam computer tomography (CBCT) datasets immediately after ORIF (T1) and after implant removal (T2), plus fractures of the condylar neck and base as a reference. 2D vertical and 3D volume changes of the condylar head after ORIF of CHFs were evaluated by CBCT datasets transformed into 3D models for 3D volumetric assessment using Slicer freeware.ResultsAmong a total of 50 fractures (38 patients), including 41 CHFs (ORIF with titanium positional screws, including 15 minor and 12 major fragmented cases) plus nine extracapsular fractures (eight upper neck and one base fracture), postoperative condylar volume decreased by a mean of 0.27 cm³ (median 0.25 cm³; SD 0.23 cm³) or 16% (median 14%; SD 11%). Major fragmented CHFs showed significantly higher resorption rates (p < 0.001, range 8–42%). Age correlated with a decrease in condylar volume (mean 2.4% per 10 years of age, (p = 0.011). No significant correlation could be established between loss of condylar volume and fracture localization. A protrusion of metallic implants was seen in 20% of the assessed cases.ConclusionDue to substantial volume changes of the condylar head occurring after ORIF, protrusion of implants (both metallic and resorbable) needs to be taken into consideration. An early removal of metallic ostheosyntesis material (around 4 months after ORIF) is strongly recommended to avoid adverse short- and long-term effects.     

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。     

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.     

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。     

Non-surgical management of paediatric and adolescent mandibular condyles: A retrospective review of 49 consecutive cases treated at a tertiary referral centre

IntroductionMandibular fractures account for over 50% of all facial fractures in children, with the majority of these occurring at the condyle. There is currently no consensus on the management of mandibular condyle fractures in the paediatric population. Treatment options range from conservative management, with or without maxillomandibular fixation (MMF) and physiotherapy, to open reduction and internal fixation (ORIF).MethodsThis was a retrospective review of all patients who attended Alder Hey Children's Hospital with fractured condyle(s) between the years 2000 and 2015. All patients were managed non-surgically and included those managed conservatively and/or with MMF. The following variables were recorded: age, sex, mechanism of injury, concomitant mandibular fractures, imaging, SORG classification, complications and follow-up intervals. The following exclusion criteria applied: patients who underwent open reduction internal fixation of their condylar fracture and patients aged 16 years or over.ResultsForty-nine patients (38 male, 11 female) underwent non-surgical management of condylar fractures during the 15-year study period. The mean age at time of injury was 12 years (range 2–15 years).The etiology of fractures comprised mechanical falls (n = 22), assault (n = 14), sport (n = 5), road traffic accident (n = 3), epileptic fit (n = 1), and unknown mechanism (n = 4). The mean length of hospital stay was 3 days, ranging from 0 to 14 days. Thirty-seven patients had a concomitant mandibular fracture and 12 had an isolated unilateral condylar fracture. Follow-up intervals ranged from 1 to 133 weeks, with a median length of 12 weeks. Fifteen patients underwent MMF, while 34 had soft diet and physiotherapy only. Ninety-two per cent of patients had no complications. No patient had failure of treatment requiring a return to theatre and/or ORIF. Occlusion, interincisal distance, asymmetry and TMJ symptoms were examined in 43/49 patients who attended their postoperative appointments. Four patients (8%) had complications in the postoperative period, namely: lateral open bite (n = 2), deviation to the affected side on wide opening (n = 1), and non-specific TMJ dysfunction (n = 1). None of these patients presented with any subjective symptoms and none developed asymmetry or needed any further surgical intervention.ConclusionPaediatric and adolescent mandibular condyle fractures can be safely and predictably managed using conservative methods. In our, albeit small, study cohort all patients were managed conservatively, and all had a satisfactory outcome with no requirement for further operative intervention.     

A comparative analysis of the efficacy of cortical screws as lag screws and miniplates for internal fixation of mandibular symphyseal region fractures: a randomized prospective study

The management of facial trauma is one of the most rewarding and demanding aspects of oral and maxillofacial surgery. Being the most prominent mobile bone of the facial skeleton, mandible fracture occurs more frequently than any other fracture. In this study, open reduction and internal fixation was performed for isolated mandibular symphyseal region fractures using cortical screws (as lag screws) in 40 patients and using miniplates in 40 patients. Clinical and radiological evaluations were made at 6 months postoperatively. Primary stability of fracture segments, postoperative swelling, restricted lip mobility, infection, wound dehiscence, implant removal, and mal-union or non-union of fracture segments was evaluated. Primary stability was achieved in 100% of cases treated with cortical screws, whereas for patients treated with miniplates, 97.5% attained primary stability, while one case (2.5%) showed persistent clinical mobility. Postoperative complications were noted in 13 (16.25%) of the total 80 patients. The duration of postoperative swelling was less in patients treated with cortical screws compared to patients treated with miniplates. It is concluded that cortical screw fixation is an effective procedure for the treatment of symphyseal region fractures, but the procedure is somewhat technically sensitive.     

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.     

Aetiology,pattern and treatment of mandibular condylar fractures in 549 patients: A 22-year retrospective study

PurposeThe purpose of this study was to retrospectively investigate the aetiology, pattern, and treatment of mandibular condylar fractures in our department over the past 22 years.Patients and methodsData of patients who sustained mandibular condylar fractures from 1988 to 2009 were recorded, including fracture aetiology, pattern of condylar fracture, time, age, sex, associated injury, patient transferred by other clinics, lag time and treatment method. Data analysis included X² test, Fisher exact test, t-test, Ridit analysis and Logistic regression analysis.ResultsThe sample was composed of 549 patients (749 condylar fractures), 404 male and 145 female (male:female = 2.79:1), with a mean age of 30.12 ± 14.44 years. Road traffic accidents were the most common cause (248, 45.2%). Condylar head fractures were significantly related to a fall at ground level (p = .001). A fall from a height had a 3.19-fold risk of bilateral condylar fractures (odds ratio, 3.19; 95% confidence interval, 1.33 to 7.65; p = .010). A majority of the condylar fractures (693, 92.5%) were treated by a surgical procedure. Condylar head were mostly removed (95.0%, p < .001), condylar neck and condylar base fractures were most frequently treated by open reduction and internal fixation with miniplates (74.4%, p < .001). Most of the dislocated condylar fractures were treated by open surgery (96.5%, p = .026).ConclusionsThe anatomic position and uni/bilateral pattern of mandibular condylar fractures were positively related to situations when considerable force is involved. Open condylar surgery was based on the level of fracture and degree of displacement or dislocation.     

自攻牵引钉应用于颌面骨折颌间牵引的并发症

目的：探讨自攻牵引钉应用于颌面骨折颌间牵引的并发症及防治对策。方法：总结2007年1月～2009年12月间颌面骨折,应用自攻牵引钉行颌间牵引30例。其中上颌骨骨折5例,下颌骨骨折25例。结果：29例咬合关系恢复至正常,1例咬合关系恢复不良。在222枚螺钉中有39（18%）枚牵引钉在拆除时发现螺钉尾部被口腔黏膜覆盖,有4（2%）枚螺钉断裂。在牵引完成前有7（3%）枚螺钉松动,未发现螺钉两侧的牙根损伤。结论：虽然自攻颌间牵引钉是一种安全,省时的颌间牵引方法,但它本身存在一定的局限性和潜在并发症,临床医生应该意识到这一点,更加安全有效地使用它。     

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.     

Prognostic factors for long-term results after condylar head fractures: A comparative study of non-surgical treatment versus open reduction and osteosynthesis

This longitudinal study compared functional, anatomical, and quality of life (QoL) outcomes after closed reduction (CR) versus open reduction and internal fixation (ORIF) of condylar head fractures (CHFs). The aim was to determine predictability of results and to establish prognostic factors for poor outcomes, thus allowing therapeutic decision making between CR and ORIF.All fractures of the non-surgical group were treated by CR with maxillomandibular fixation (CR-MMF) according to an managed analogically. Morphological and functional results were acquired using axiography and clinical functional diagnostics, as well as MRI in problematic cases. Outcomes were compared with those of a collective of patients treated by ORIF with small fragment screws (SFS), according to a uniform standard.A total of 26 patients with 29 unilateral and bilateral CHFs of the non-surgical group were examined over a period of 28.5 months after completion of therapy and compared with a collective of 54 patients with 73 CHFs treated by ORIF. Statistically significant differences were found between both groups in protrusion and mediotrusion on the fracture side, in favour of ORIF. Significantly more patients in the ORIF group were symptom free in terms of the Helkimo dysfunction index and the RDC TMD compared with conservatively treated patients. Associations between Angle class and Helkimo dysfunction index, and between occlusion or number of teeth and pain after CT, could be confirmed.Given their respective indications, both treatment options demonstrated acceptable results in the majority of cases. However, for therapeutic decision making, it is crucial that the long-term results after CR are significantly less predictable. Our study showed only few positive prognostic factors for a stable functional outcome after CR such as isolated CHFs with stable occlusal conditions in younger patients (<25 years).     

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。     

侧向品形长钛钉内固定治疗髁突矢状骨折的临床应用

目的　探讨侧向“品”形长钛钉内固定技术治疗下颌骨髁突矢状骨折（SFMC）的临床方法及疗效。方法　依据上下颌骨三维CT重建结果,对SFMC内侧骨折片≥1/3髁突头长的27例(39侧),根据CT测量髁突内外侧径长度值结果,行SFMC解剖复位后,侧向用3枚16 mm长钛钉行“品”形内固定,术后1、3、6个月进行临床和影像学复查。结果　27例(39侧)病例的髁突外形良好,钛钉无松动、脱落,髁突内侧骨折片无移位,下颌运动和功能满意,开口度≥3.5 cm。结论　“品”形长钛钉侧向内固定治疗SFMC固定稳固,操作简单,省时,创伤小,疗效确切,术后3月可以评价其效果;对其与髁突增龄性变化的关系还有待进一步观察。     

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。     

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.