Endoscope-assisted transoral reduction and internal fixation versus closed treatment of mandibular condylar process fractures--a prospective double-center study

Transoral endoscopic assisted reduction and internal fixation of mandibular condylar neck fractures with short condylar segment

This study aimed to assess the reliability and safety of transoral endoscopic-assisted reduction internal fixation (TERIF) for treating short-segment condylar neck fractures (CNF), including hardware removal. Patients with displaced CNF and short condylar segments treated using TERIF were included in the study. Clinical evaluation covered dental occlusion, range of mouth opening, deviation during mouth opening, protrusion, laterotrusion, pain, and chewing. Radiological evaluation was used to assess fracture displacement, angulation, head dislocation, postoperative reduction, fixation stability, and bone healing. The same technique was used to treat 15 patients with 18 CNF and short condylar segments. Hardware removal was performed for nine fractures in eight patients after fracture healing using the same approach. All patients regained satisfactory, pain-free mouth opening with no deviation and complete bone healing. Computed tomographic images displayed adequate reduction and stable fixation during the follow-up period for all patients. No temporary or permanent facial nerve impairment occurred in any of the patients. TERIF is a reliable and safe treatment for CNF with short condylar segments, even in the presence of head dislocation, medial override, and malunited fractures; hardware can be safely removed after healing using the same approach.

A single-centre retrospective 10-year experience of the rhombic 3D condylar fracture plate for open reduction and internal fixation of condylar neck and base fractures

Fractures of the mandibular condyle account for a significant proportion of mandibular fractures. The specific functional loads require particular specifications for the implant design used for open reduction and internal fixation of such fractures. The clinical and radiographic outcomes in patients treated using a single rhombic 3D condylar fracture plate for open reduction and internal fixation at a single institution, and who fulfilled the inclusion and exclusion criteria, are presented. The primary outcome variables were: occlusion, maximum interincisal distance and mandibular excursion at 1, 3, and 6 months postoperatively, and radiographic measurements for mandibular height and gonion angle. In total, 263 patients were included, of whom 173 (65.8%) were male and 90 (34.2%) female. The mean age was 40.4 ± 18.9 years. There was satisfactory occlusion in 98.9% of patients at the 6-month follow-up, and a significant improvement in all parameters for mandibular excursion (p < 0.001), with a reduced ramus height and an increase in the gonion angle on the fractured side. Excellent clinical and radiographic results were achieved using the rhombic-shaped implant, deeming it appropriate for the osteosynthesis of mandibular condyle fractures.

Endoscopic-assisted intraoral approach for mandibular condyle fracture management: A systematic review and meta-analysis

OBJECTIVE

Surgical innovation led to an endoscopic-assisted intraoral approach for managing condyle fractures. The purpose of this systematic review is to purview the role of the endoscope and determine the range of information, summarizing the evidence for the benefit of surgeons on an endoscopic-assisted intraoral approach.

STUDY DESIGN

A literature search was conducted in PubMed, Google Scholar, Semantic Scholar, and Cochrane Library databases for studies mentioning the endoscopic intraoral approach for managing mandibular condylar fractures. Outcomes include the role of the endoscope, challenges, adjunct armamentarium, duration, and complications associated with the transoral and transbuccal approach for screw fixation. The meta-analysis was conducted with prevalence estimates and standardized means using STATA.

RESULTS

Thirty-nine studies were included. A 30° angulated, 4-mm-thick endoscope was the most commonly used endoscope. Two mini plates were most commonly used for fixation. Facial nerve weakness was higher in the transbuccal approach (1.24%) than in the transoral approach (0.8%). Pooled analysis (6 studies) showed that the duration of the surgical procedure was less in the transoral approach compared with the transbuccal approach for screw fixation. The bailout was 1.49%.

CONCLUSIONS

The endoscopic-assisted intraoral approach is reliable for condylar fracture management. The transoral and transbuccal approaches can be used for screw fixation with comparable outcomes.

Evidence-Based Medicine for Mandible Fracture Repair: Current Controversies and Future Opportunities

Mandibular fractures are among the most common facial fractures resulting from trauma. The nature of the injury, involved facial structures, presence of associated injuries, the dental status of the patient, comorbid conditions, and psychosocial context all must be considered by the surgeon when planning the optimal treatment for these patients. While consensus exists for many aspects of the management of mandibular trauma, some elements remain controversial. Three such topics-antibiotic therapy, treatment of subcondylar fractures, and management of the third molar-remain particularly controversial, with significant heterogeneity in practice patterns and without widely accepted evidence-based guidelines to standardize care. The goals of this work are to (1) review the historical perspective underlying these controversies, (2) summarize recent evidence shaping the current debate, and (3) highlight opportunities for continued efforts to identify best practices.

Can malocclusion provide clinicians with information for differential diagnosis of temporomandibular joint diseases?: A review

The aim of this literature review was to summarize the clinical characteristics and symptoms of temporomandibular joint diseases, and to discuss the associations between temporomandibular joint diseases and categorization of malocclusion. Electronic literature searches were performed using the PubMed database. The authors established a differential diagnostic method for temporomandibular joint diseases related to malocclusion. A literature search using PubMed yielded 213 texts, of which based on exclusion criteria, 28 were included in this study. Malocclusions were categorized into 5 types. The authors suggested a diagnostic tree of temporomandibular joint diseases based on the types of malocclusion and 4 variables in clinical characteristics and symptoms. Clinicians treating malocclusions must attempt to clarify the cause of the occlusal condition. If caused by temporomandibular joint disease, it is important to make a proper differential diagnosis at first, and not to overlook the causative disease. Further clinical knowledge of associations between temporomandibular joint diseases and malocclusions should be accumulated, and the diagnostic tree should be improved based on new information.

Functional Rehabilitation after Mandibular Fracture - A Systematic Review

Background

The objective of this study was to evaluate the efficiency of functional rehabilitation in terms of mouth opening, quality of life, healing process, occlusion and dysfunction, between different treatment methods, after condylar fractures, based on the current literature.

Methods

Using the PRISMA guidelines in search of clinical trials published between 2011 and 2021, a literature analysis was performed. This search was conducted using the following Medical Subject Headings (MeSH) terms: rehabilitation OR mouth opening recovery OR function recovery AND mandibular fracture OR condylar fracture.

Results

The literature search resulted in a total of 110 study articles, of which seven publications were used in the present review, according to a selection based on the pre-established eligibility criteria. The review showed that open reduction resulted in a better three-dimensional recovery of mandibular movements and revealed greater results regarding the absence of the symptoms after applied treatment. However, studies assessing closed reduction, especially performed with intermaxillary fixation screws (IMFS), revealed excellent results in terms of quality of life, mouth opening and occlusal parameters.

Discussion

This systematic literature review showed that open reduction resulted in a better three-dimensional recovery of mandibular movements and showed greater results regarding the absence of symptoms. However, studies assessing CR, especially those performed with IMFS, revealed excellent results in terms of quality of life, mouth opening and occlusal parameters.

Endoscopically Assisted Treatment of Condylar Base and Neck Fractures: A Single Institution Analysis of Outcomes and Complications

Background

Conservative treatment, including observation and closed treatment, as well as open reduction and internal fixation are existing options for treating condylar process fractures. Extraoral approaches are widely preferred for open reduction and internal fixation. Transoral access for condylar base and neck fractures is not yet commonly used as it is technically demanding and requires special equipment.

Purpose

In this study, the transoral endoscopically assisted approach is described, and its outcomes and complications were investigated. Imaging data and clinical records of 187 patients with condylar process fractures, treated via endoscopically assisted transoral approach between 2007 and 2017 were analyzed. Parameters included diagnosis and fracture classification, treatment, osteosynthesis configuration and postoperative complications.

Results

Early complications, including infection, transient postoperative malocclusion, pain and limited mouth opening, occurred in 35 patients (18.7%). Late onset complications, such as screw loosening were documented in only 4 patients (2.1%). Revision surgery following postoperative 3D imaging was required in only 3 cases (1.6%). Fragment length ranged from 15.5 to 38.3 mm. In 57.7% of patients with condylar fragment length < 20 mm, a single osteosynthesis plate was used, with no elevated complication rate. Two osteosynthesis plates with 4 screws each was used as standard in longer fragments.

Conclusion

Endoscopically assisted transoral treatment of condylar process fractures is a reliable, yet technical demanding technique. It allows for reduction and fixation of fractures with a condylar fragment length of > 15 mm with low postoperative complication and revision rates.

Mandibular Subcondylar Fracture: Improved Functional Outcomes in Selected Patients with Open Treatment

BACKGROUND

Subcondylar fractures represent 25 to 35 percent of all mandibular fractures, yet the treatment paradigm has remained controversial. Closed treatment relies on the plasticity of the condyle head during recovery, whereas open treatment is challenging and risks facial nerve injury. Perioperative, functional, and patient-reported outcomes were measured to compare methods of open versus closed treatment of subcondylar fractures.

METHODS

Selected displaced subcondylar fracture cases with open (open reduction and internal fixation of subcondylar fracture with maxillomandibular fixation) versus closed (maxillomandibular fixation) treatment were compared (n = 60). Demographics, perioperative data, complications, persistent symptoms, chin deviation, malocclusion, change in mouth opening, functional scores, and FACE-Q patient satisfaction were recorded.

RESULTS

Open versus closed groups had similar demographics and perioperative data, except the open group had longer operating room time (76.39 minutes versus 56.15 minutes). In long-term follow-up, open-treated patients had fewer symptoms (9 percent versus 67 percent), less chin deviation (0 percent versus 40 percent), a less restricted mouth opening (3mm versus 5mm), and better functional scores (1.92 versus 0.861). Transient facial nerve weakness was seen in 6 percent of open cases.

CONCLUSION

For selected subcondylar fracture patients, open treatment with endoscopic assistance, nerve monitoring, and specialized plates provides superior long-term results compared to closed treatment when considering symptoms and functional parameters.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Endoscopic surgery versus open reduction treatment of mandibular condyle fractures: A meta-analysis

The aim of the study was to compare open reduction with internal fixation (ORIF) and endoscopic open reduction with internal fixation (EORIF) of condylar fractures (CF) in adults in terms of reducing both needing of reoperation and/or facial nerve injury. An electronic search was undertaken (PubMed/MEDLINE, Web of Science, SCOPUS, and The Cochrane Library). The inclusion criteria were full text, published from their inception to June 2020, clinical trials, randomized or not, and retrospective studies, that compared ORIF and EORIF. The estimates of an intervention were expressed as the risk ratio (RR). From the 1338 articles found, 5 publications were included. There was no statistically significant difference between ORIF and EORIF regarding needing of reoperation (RR = 2.46, p = 0.42) or facial nerve injury (RR = 0.45, p = 0.14). Meta-analysis suggests that there is no difference between open reduction with internal fixation (ORIF) and endoscopic open reduction with internal fixation (EORIF) of condylar fractures (CF) regarding facial nerve injury risk or need for reoperation.

Comparison between 3D delta plate and conventional miniplate in treatment of condylar fracture: A randomised clinical trial

The aim of the study was to conduct a randomized clinical trial comparing the efficacy of standard non-compression miniplate and 3-dimensional (3D) titanium plate in the open reduction internal fixation (ORIF) of the mandibular condylar fractures. Patients who underwent open reduction of mandibular condylar fracture were recruited for the study. The patients satisfying the inclusion criteria were randomly assigned to two groups in a 1:1 ratio. Group A comprised patients treated using conventional miniplates, and Group B comprised patients treated using 3D Delta Plate. Informed consent was provided. All the patients underwent ORIF under GA via retromandibular approach. The sample size was set at 20 participants, with 10 participants in each group who were randomly allocated. Our study showed that patients in Group A had a significant statistical difference operating time (141.20 ± 2.59 min) than that of Group B (117.2 ± 9.63 min). Mouth opening was significantly greater in the 3^rd-month follow-up in Group B (mean = 42.40 ± 1.82) compared to Group A (mean = 35.80 ± 1.30). Biting efficiency in Group B was observed to be clinically and statistically better compared to Group A (P = 0.012). Wound dehiscence was managed efficiently by judicious use of antibiotics and wounds were free of any signs of infections or discharge in the consecutive follow-ups. No plate removal was required in either group. Patients treated with 3D delta plates have superior outcomes with regard to operation time, mouth opening, and biting efficiency compared with miniplates. Hence, it can be concluded that the triangular shape of the 3D Delta plate allows the stress distribution to be superior and multidimensional, leading to better post-operative stability, faster healing, and reduced complications.

Does magnitude of deformity correlate with functional outcome following closed reduction in unilateral condylar fracture?

Introduction: Condyle fracture can be treated surgically (ORIF) or conservatively (CTR). When treated by CTR, the fracture might not heal in a morphologically ideal shape. The severity of the deformity and its effects on the functional outcome is not known. This study would investigate the anatomical outcome of CTR and its effect on the functional outcome. Methods: Using a cross-sectional study design, we enrolled patients identified from our trauma census that meets the pre-determined inclusion criteria. Patient underwent assessment which involves clinical and radiographic evaluation. Clinical examination was done by using Helkimo Index. Radiographic evaluation by using cone beam computed tomography (CBCT) scan were traced and digitized, and the position and morphology of the fractured mandibular condyle was measured and compared with those of the contralateral non-fractured condyle in the axial, coronal and sagittal planes. Radiographic data was then compared with data from clinical examination. Results: 25 patients with unilateral condyle fracture and met the inclusion criteria were identified. Eight patients were successfully recalled and included in the study. Assessment was done on average of 40 months post-treatment. Clinical assessment with Helkimo Index showed that 63% had at least mild temporomandibular symptoms or dysfunction. CBCT examinations revealed that most patients had morphologically deformed healed condyle. No pattern can be seen in the magnitude of deformity with functional outcome. Conclusions: Following CTR, condyle fracture would heal in a morphologically deformed shape. Satisfactory functional outcome is still attainable despite this. The magnitude of the deformity does not appear to influence the functional outcome.

Comparative Evaluation of Clinical and Radiological Outcomes of Retromandibular Transparotid and Transoral Endoscopic-Assisted Approach for Surgical Management of Mandibular Subcondylar Fractures

Study Design

A prospective randomized comparative study was conducted to evaluate the clinical and radiological outcomes of the retromandibular transparotid (RMT) approach with endoscopic-assisted transoral (ENDO) approach used for open reduction and internal fixation (ORIF) of adult mandibular subcondylar fractures.

Objectives

To evaluate and compare the primary functional outcome using the Helkimo's dysfunction index, the surgical ease, the incidence of facial nerve weakness, the cosmetic outcomes and the number of complications following ORIF of mandibular subcodylar fractures using the RMT and ENDO approaches.

Methods

In this prospective study, 20 patients with unilateral/bilateral subcondylay fractures requiring ORIF were recruited between 2017 and 2018. Patients were randomly divided into RMT and ENDO group, 10 patients in each. Clinical and radiological assessment was done preoperatively and in postoperative period it was done at different intervals over the period of 6 months. The intraoperative parameter time taken during surgery was correlated for association with the time elasped since day of trauma and with the fracture severity. Similarly, the presence of multiple fractures of the mandible and postoperative occlusion were evaluated for the association.

Results

Comparable functional results were noted in both groups without any statistical significance. ORIF in ENDO group proved to be more time-consuming. For the RMT group, visible scars were rated best or close to best at the end of 6 months but a greater number of facial nerve injuries were reported in the RMT group.

Conclusions

Superiority of one approach over others cannot be established since the outcomes were not statistically different. However, the ENDO approach appears to be safer. Therefore, there is a need for the development of innovative armamentarium which would improve the dexterity and ease of the surgeon and hence the total time taken for this minimally invasive approach for the management of subcondylar fracture.

Radiologic Analysis of Surgically Treated Fractures of the Condylar Process by an Endoscopic-Assisted Transoral Approach

PURPOSE

This study analyzed the radiologic outcomes of patients with unilateral mandibular condylar fractures treated with open reduction-internal fixation (ORIF) through a transoral approach.

PATIENTS AND METHODS

In this retrospective study, the radiologic images of 40 patients who underwent open reduction-internal fixation through a transoral approach were presented to 2 independent examiners. All patients underwent the surgical procedure between January 2015 and December 2016 at the Department of Cranio-Maxillofacial Surgery at UniversitätsSpital Zürich and were included in a previous functional outcome study. The surgical results were analyzed and graded as poor, acceptable, or good. The examiners declared whether they would have made any intraoperative revisions if the radiologic information had been available. Finally, the examiners estimated the required duration of elastic intermaxillary fixation (IMF) from the radiologic images, which was compared with the actual duration.

RESULTS

Fracture reduction was classified as good in 33 cases (82.5%), acceptable in 5 cases, and poor in 2 cases by one examiner and as good in 32 cases (80%), acceptable in 6 cases, and poor in 2 cases by the other examiner. The inter-rater reliability was determined to be good (Cohen κ = 0.92). Correct osteosynthesis placement was found in 19 cases by one examiner and in 21 cases by the other examiner, with good inter-rater reliability (κ = 0.8). Moderate inter-rater reliability (κ = 0.4) was found for the required duration of elastic IMF. Furthermore, the estimated elastic IMF duration matched the actual duration in fewer than half of the cases.

CONCLUSIONS

It is feasible to achieve reliably good radiologic results when operating on condylar process fractures by a transoral approach with endoscopic assistance and angled instruments. Intraoperative 3-dimensional imaging enables instant quality control and prompts surgical revision if needed.

Clinical experience and results with a Rhombic Plate for transoral endoscopically-assisted osteosynthesis of fractures of the condylar neck

The intraoral approach is favoured by many patients and surgeons for the treatment of fractures of the condylar neck, but the limited space offered by this approach can make positioning and fixation of the osteosynthesis plate difficult. A rhombic-shaped plate was designed specifically for use with the intraoral approach, and introduced into our clinical practice in 2012. We present the clinical and functional results in 81 patients with 98 fractures of the condylar neck who we have treated with this technique. Of these six required surgical revision, and ultimately all but two had satisfactory occlusion and mandibular function. Our complication rate of 6/81 (7.4%) compares favourably with those reported elsewhere, and confirms that open reduction and internal fixation of condylar fractures using the Rhombic plate through an intra-oral approach provides good outcomes.

The "European zygomatic fracture" research project: The epidemiological results from a multicenter European collaboration

PURPOSE

Fractures of the zygomaticomaxillary complex (ZMC) are common injuries that may lead to loss of an aesthetically pleasing appearance and functional impairment. The aim of this study was to analyze the demographics, causes, characteristics, and outcomes of zygomatic fractures managed at several European departments of oral and maxillofacial surgery.

MATERIALS AND METHODS

This study is based on a multicenter systematic database that allowed the recording of all patients with ZMC fractures between 1 January 2013 and 31 December 2017. The following data were recorded: gender, age, personal medical history, etiology, side of zygomatic fracture, classification of ZMC fracture, associated maxillofacial fractures, symptoms at diagnosis, type of performed treatment, and sequelae/complications.

RESULTS

A total of 1406 patients (1172 males, 234 females) were included in the study. Statistically significant correlations were found between assault-related ZMC fractures and the A3 class (p < .0000005) and between Infraorbital Nerve (ION) anesthesia and B class (p < .00000005).

CONCLUSION

The most frequent cause of ZMC fractures was assault, followed by falls. The most frequently involved decade of age was between 20 and 29 years. The decision and type of surgical treatment of ZMC fractures depends on several issues that need to be considered on a case by case basis.

Are Facial Asymmetry and Condylar Displacement Associated With Ramal Height and Treatment Outcomes in Unilateral Condylar Fracture When Managed by the Closed Method?

PURPOSE

This study measured the mandibular ramal height in patients with unilateral condylar fractures managed by the closed method using elastic intermaxillary fixation. Its correlation with facial asymmetry and condylar displacement was assessed. This will determine whether the treatment outcome is in favor of the closed or open method.

MATERIALS AND METHODS

A prospective cohort study was performed. The study included patients with unilateral condylar fractures who reported to SDM Craniofacial Surgery and Research Centre, Dharwad, India. All patients in the study were managed by the closed method (nonsurgically using arch bars and elastic intermaxillary fixation). Standardized panoramic radiographs were used to assess ramal height and condylar displacement in the sagittal plane. Posteroanterior mandible and reverse Towne radiographs were used to assess facial asymmetry and condylar displacement in the coronal plane before treatment; immediately after treatment; and at 3, 6, and 12 months of follow-up. Data were subjected to statistical analysis using the analysis-of-variance test and the Pearson correlation coefficient method.

RESULTS

The study included 25 patients with unilateral condylar fractures managed by closed treatment; they showed a significant reduction in ramal height on the affected side by 1.15 mm (P = .0001) at 12 months' follow-up. The change in facial asymmetry was reported as 1.05 mm (P = .0016) at 12 months' follow-up. Its correlation with ramal height was noted to be insignificant (P = .07). The only significant correlation noted between facial asymmetry and condylar displacement was in the coronal plane at 12 months' follow-up (P = .04).

CONCLUSIONS

A weak positive correlation was noted among the assessed values on radiographs obtained during the 12-month follow-up. Facial symmetry was not greatly affected when the ramal height at the time of injury on the fractured side was reduced by 3.25 ± 0.6 mm.

Mandibular Subcondylar Fractures: A Review on Treatment Strategies

Condylar injuries are often subjected to discussion and controversy in maxillofacial surgery as they constitute many of the facial fractures. The condylar area has a great clinical value due to its important components. Vital components in this area are susceptible to functional disability due to either the fracture itself or the subsequent surgical intervention. Each of the strategies for the management of these fractures has its advantages and disadvantages. As there are controversies around management of condylar fractures, different treatment modalities are suggested in literature, so this paper reviews different treatment strategies of the following types of fractures in adults: 1-Closed reduction with maxillomandibular fixation, 2-Open reduction with internal fixation, 3-Endoscopic-assisted reduction with internal fixation. In conclusion, we declare that the endoscopic surgery is certainly a good replacement for approaches through the skin, for subcondylar fractures, but still more randomized clinical trials are needed to be carried out on this issue.