Surgical complications with open treatment of mandibular condylar process fractures

Distribution, scaling, and depiction of the temporal branches of the facial nerve

Iatrogenic injury to the temporal branches of the facial nerve (CN VII) is the leading postoperative complication of the preauricular surgical approach to the temporomandibular joint (TMJ). Many of the anatomical illustrations vary greatly in how the anatomy of the temporal branches of the facial nerve are depicted. Additionally, there are few studies that discuss this variation. This study aims to provide more accurate data on this discrepancy. Here, the distribution of temporal branches of the facial nerve was examined in 20 cadaveric donors. A count of branches and the location of each was mapped as they crossed the zygomatic arch, with attention paid to variation in the breadth of the nerve free "preauricular window" which is pertinent to the surgical access to the TMJ. Comparable measures were collected from published anatomical illustrations and tested for accuracy. Preauricular window breadth measurements were found to be comparable to previous studies, but the mean value was lower here. Patterns in the nerve distribution fit a proportional model whereby the zygomatic length (ZL) is divided into five equal segments, the most posterior of which was found to be free of CN VII branches in all donors. In anatomic illustrations, the number of nerve branches crossing ZL was undercounted and the breadth of the preauricular window was overestimated. Results suggest that controlling for face size could reduce the variation observed in the breadth of the facial nerve-free zone near the TMJ. Non-cadaveric reference illustrations do not represent the anatomy accurately.

Primary surgery of subcondylar mandibular fracture using patient-specific implant: the Helsinki protocol

PURPOSE

Preoperative virtual planning and osteosynthesis with patient-specific implants (PSIs) have become a quotidian approach to many maxillofacial elective surgery setups. When a process is well-organized, a similar approach can be harnessed to serve the needs of exact primary reconstructions, especially in midfacial trauma cases. PSI osteosynthesis of the mandible is, however, more challenging because a mirror technique of the facial sides is often unreliable due to inherent lack of symmetry, and movement of the mandible increases the risk of loosening of the osteosynthesis. The purpose of this study was to present clinical results of the Helsinki protocol concept of utilizing PSIs in the primary surgery of unilateral mandibular subcondylar fractures as the first publication on the subject.

METHODS

A single-center study of a new Helsinki protocol is presented for surgical treatment of subcondylar mandibular fractures using patient-specific, titanium-milled repositator plates. Ten patients with dislocated subcondylar mandibular fractures received surgery and osteosynthesis with PSI via a retromandibular approach.

RESULTS

Clinical and radiological outcomes were excellent; none of the patients had fixation-related major complications or developed postoperative malocclusion.

CONCLUSIONS

Study results show that the Helsinki protocol, treating mandibular condylar fractures primarily with PSI plates, is a viable treatment option.

Minimal Access Retromandibular Approach to Fractures of Vertical Segment of the Mandible: A Versatile Technique

Introduction  Fractures of the condylar region of the mandible, although fairly common, also generate the most debate regarding management-both closed and open treatment options have been recommended and shown to yield good results. We present our experience with a minimal access retromandibular approach to fractures of the vertical mandible. Materials and Methods  This is a retrospective study of all patients who underwent open reduction and internal fixation for fractures of the vertical mandible (condyle, subcondylar region, ramus) using a retromandibular approach at a tertiary care hospital in a metropolitan city in India between January 2022 and July 2023. All fractures were approached using a standard technique through a retromandibular incision and a transparotid route. The proximal segment was mobilized, reduced, and fixed to the ramus with two 2-mm miniplates-one along the posterior border and the other along the sigmoid notch border. Postoperative guiding elastics were placed for 2 weeks without any rigid maxillomandibular fixation. Patients were followed at weekly intervals for 1 month followed by monthly visits for 6 months. At each visit, mouth opening, occlusion, and facial nerve function were assessed. Scar quality was assessed by both examiner and patient using the Patient and Observer Scar Assessment Scale (POSAS) scoring system. Results  A total of 25 subcondylar fractures in 20 patients were fixed using the retromandibular approach. Nineteen were male and 1 was female. The etiology of trauma was road accident (8), fall from train (2), fall from height (5) and assault (5). Fifteen patients had unilateral fractures while 5 had bilateral fractures. All patients had concomitant fractures of the mandibular arch which were also fixed. The interval between trauma and surgery ranged from 5 to 28 days. All patients had premature molar contact on the side of fracture with anterior open bite. Mouth opening ranged from 1.5 to 2.5 cm. All the fractures could be fixed using the retromandibular approach. None of the patients developed any facial nerve dysfunction or salivary leak. The occlusion was restored to pretrauma status in all patients and was stable at 6 months' follow-up. Mouth opening ranged from 3.5 to 4 cm. The POSAS observer score ranged from 09 to 19 with a mean score of 12.7. The POSAS patient score ranged from 17 to 28 with a mean score of 20.3 revealing that all patients were extremely happy with the scar. Conclusion  The minimal access retromandibular approach to the vertical mandible is a versatile technique enabling accurate reduction and fixation of fractures of the vertical segment of the mandible with good long-term functional and cosmetic results.

Complications of Open Reduction and Internal Fixation of Mandibular Condyle Fractures in Oman

Objectives

This study aimed to report the complication rate associated with open reduction and internal fixation (ORIF) of mandibular condyle fractures in Oman.

Methods

This retrospective cohort study was conducted among patients who underwent ORIF of mandibular condyle fractures at Al-Nahdha Hospital and the Sultan Qaboos University Hospital in Muscat, Oman, from January 2008 to December 2020. Data collected included patient demographics, fracture aetiology, fracture side and type, surgical approach and recorded complications and outcomes.

Results

A total of 68 patients (59 males and 9 females; mean age of 30.1 years) with 83 mandibular condyle fractures underwent ORIF during the study period. Subcondylar fractures were the most common type, occurring in 62.7% of patients, while bilateral fractures were observed in 21 (30.8%) patients. The most common surgical approach was retromandibular, used in 42.2% of patients. The overall complication rate was 42.6%, with the most frequently reported complications being transient facial nerve palsy (18.1%), malocclusion (14.7%) and restricted mouth opening (10.3%). Subsequent surgical interventions to correct malocclusion were performed in 6 cases. There was no statistically significant association between the overall complication rate and the patients' clinical characteristics.

Conclusion

Although ORIF of mandibular condyle fractures generally offers favourable outcomes, it carries a risk of complications.

Modified Endaural Approach With a Peripheral Dissection of the Superficial Musculoaponeurotic System to Access the Temporomandibular Joint to Prevent Facial Nerve Injury

The purpose of this study was to assess the effects of protecting the facial nerve with a modified endaural approach with a peripheral dissection of the superficial musculoaponeurotic system to access the temporomandibular joint which allows an excellent operative field of visualization, multiple surgical procedures of the temporomandibular joint, and general care which improves the immediate postoperative period, making this a less morbid surgery. This study included 33 patients (39 sides) who underwent surgical treatment for disorders of the temporomandibular joint from the years 2021 to 2023 at the maxillofacial department of the clinic "Colsanitas" located in Bogota, Colombia. Therapeutic results were evaluated by postoperative facial nerve injury, with the House-Brackman scale; every patient was examined for adequate facial musculature function immediately after surgery. Notably, zero patients presented facial nerve injury. These results imply that the modified endaural approach with a peripheral dissection of the superficial musculoaponeurotic system to access the temporomandibular joint reduces the incidence of facial nerve injuries, improves operative site exposure, and lowers the frequency of complications.

Mandibular condylar fractures: a 5-year retrospective analysis comparing open versus closed reduction

BACKGROUND

Mandibular fractures are common facial fractures, and contemporary management of mandibular condylar fractures is controversial. The purpose of this study was to compare the outcomes of patients who sustained a mandibular condylar fracture between 2016 and 2020, who were managed by either open or closed techniques. The outcomes of this study were: post-operative facial nerve function, occlusion, and maximal mouth opening.

METHODS

This study is a retrospective multicentre cohort study which assessed clinical records for 246 patients with mandibular condyle fractures in three hospitals in Perth, Western Australia. The primary outcome measure was changes in post-operative facial nerve function.

RESULTS

One hundred and thirty-two patients underwent open reduction and internal fixation (ORIF), and 114 patients had closed management. The overall rate of temporary facial nerve injury following ORIF was 3.28%. The overall rate of permanent facial nerve injury was 0.82%. Sialocoele occurred in 2.46% of all patients who underwent ORIF. 6.14% of patients had persisting malocclusion across both groups. There was a statistically significant association between the degree of fragment shortening and facial nerve injury (P = 0.0063), with more facial nerve changes in the group with 5 mm or greater of fragment shortening.

CONCLUSIONS

There is still significant debate over the management of mandibular condylar injuries. This study demonstrates a similar rate of temporary and permanent facial nerve injury as previously described, as well as a similar rate of sialocoele occurrence. Further prospective studies may provide clarity about important characteristics that will help guide decision making for mandibular condylar fractures.

Incidence of Facial Nerve Injury and Sialocele Formation Following Mandibular Condylar and Sub-condylar Fracture Fixation

Purpose

To study the incidence of sialocele formation in the parotid gland and to study the incidence of facial nerve affliction following treatment of mandibular condylar and sub-condylar fractures.

Materials and methods

The present study is a retrospective study conducted on a total of 82 patients with 107 sub-condylar and condylar fractures treated in this centre from August 2008 to August 2020. The surgical approaches used to treat the fractures were considered, and the occurrence of sialocele, salivary fistula and facial nerve paralysis was noted. The facial nerve function was analysed using House-Brackmann system of classification.

Results

The incidence of sialocele formation was seen in 15.87% of cases, and the incidence was seen more commonly during a preauricular approach (52.94%) followed by retromandibular (41.17%) followed by anterior parotid transmassetric approach (11.76%). The incidence of facial nerve affliction was seen in 17.57% of cases with majority of them showing temporal branch involvement in 21.05% of cases.

Conclusion

During the treatment of condylar and sub-condylar fractures, the facial nerve is at considerable risk of damage; however, understanding the anatomy of the nerve is of importance to avoid such complications. Sialocele formation is also an undesirable complication of such surgeries, a prompt diagnosis and early treatment is mandatory to overcome further unwanted sequel.

Open vs Closed Management of Condylar Fracture Our Experience of 100 Cases in a Suburban Tertiary Care Hospital

Study Design

Retrospective Observational Study.

Objective

Mandibular condyle fractures are distinctive among maxillofacial injuries in which they disrupt mandibular function in a way that other traumatic injuries do not. Condylar fractures can be treated using either the conservative (closed reduction and immobilisation) or surgical (open reduction and internal fixation) approaches. Both of these modalities of treatment have advantages and disadvantages, as well as indications and contraindications. The purpose of this study is to compile and compare our experience in the management of condylar fractures through open and closed reduction.

Methods

The present retrospective analysis included a total 100 patients of condylar fractures in patients > 18 years of age who were randomly divided into nonsurgical and surgical group based on Edward Ellies criteria. In the present study, the outcomes of conservative vs surgical management of condylar fractures were discussed in terms of seven parameters, including the maximal inter-incisal mouth opening, protrusive and lateral excursive movements of the mandible, status of occlusion, deviation of mandible during mouth opening, temporo-mandibular disorders and facial nerve paralysis which were measured and evaluated pre- and post-operatively at different intervals of time. Follow-up period was for 6 months.

Results

It was noted that the main cause of condylar fracture was trauma with a male predilection with an average age of 32.6 ± 1.2 years. Subcondylar fracture was the commonest type of condylar fracture that we encountered. 33.3% of the patients had restricted mouth opening and 57% of the patients had deranged occlusion. 37% of the patients were treated surgically and 48.6% of these fractures were approached using peri-angular approach. More patients had an increased mouth opening and a stable occlusion at the 6 months follow-up when compared to that of the 2 month follow up.

Conclusions

From the above study we can conclude that the treatment plan should be patient specific and follow the algorithm for a particular type of fracture. We endorse the same based on our experience in treating condylar fractures over the last 5 years. The art of decision making solely depends on the surgeon's expertise in managing condylar fractures.

Patient's Perception of Outcome after Extracapsular Fractures of the Mandibular Condyle Differs from Objective Evaluation-Experience of a Third-Level Hospital

Background: The aim of this study is to assess patients' subjective perception of treatment outcome after extracapsular fractures of the mandibular condyle. Methods: A questionnaire survey regarding facial nerve palsy (FNP), malocclusion, pain, reduction in maximum mouth opening (MMO) and further discomfort after 3, 6, and 12 months was carried out. Patients aged 18 or more presenting with an extracapsular condylar fracture between 2006 and 2020 were identified by purposive sampling Questionnaires were received from 115 patients. Fractures were classified on the basis of the pre-treatment imaging, the way of treatment was obtained from patients' medical records. Data were analyzed using Pearsons' chi-square-test, descriptive statistics and Student's t-test. Results: 93.0% of the fractures were treated by open reduction and internal fixation (ORIF). MMO reduction was the most common post-treatment complication (55.6%). ORIF was associated with less pain after 3 months (p = 0.048) and lower VAS scores compared to conservative treatment (p = 0.039). Comminuted fractures were more frequently associated with post-treatment malocclusion (p = 0.048), FNP (p = 0.016) and MMO reduction (p = 0.001). Bilateral fractures were significantly accompanied by malocclusion (p = 0.029), MMO reduction (p = 0.038) and pain occurrence (p < 0.001). Conclusions: Patients report less pain after ORIF. Comminuted and bilateral fractures seem to be major risk factors for complications. Subjective perception of complications after extracapsular condylar fractures differs from objectively assessed data.

Treatment of extracapsular fractures of the mandibular condylar process: A retrospective evaluation of 377 cases

BACKGROUND/AIM

Mandibular condylar fractures represent 25%-35% of all mandibular fractures. Despite profound research, there is still a controverse debate about treating these fractures conservatively or by open reduction and internal fixation (ORIF). The aim of this study is to analyse the outcome after open and closed treatment of extracapsular mandibular condyle fractures regarding general characteristics, post-treatment malocclusion, facial nerve palsy (FNP), maximum mouth opening (MMO) and parotid complications.

METHODS

A retrospective cohort of 377 fractures (350 open, 27 closed treatment) was reviewed by reference to clinical and radiological pre- and postoperative documentation. Follow-up period was 12 months. Pearsons' chi-square-test, correlations, Kruskal-Wallis test and t-test were carried out for statistical analysis.

RESULTS

The dominant type of fracture was type II in Spiessl and Schroll classification (50.1%). In the open treated fractures, the most common approach was retromandibular transparotid (91.7%). Post-treatment malocclusion occurred in 18.0% and was significantly increased in bilateral fractures (p = .039), in luxation fractures (p = .016) and in patients with full dentition (p = .004). After open reduction and internal fixation (ORIF), temporary FNP was documented in 7.1% whereas a permanent paresis occurred in 1.7%. FNP was significantly associated with high fractures (p = .001), comminution (p = .028) and increased duration of surgery (p = .040). Parotid complications were significantly associated with revision surgery (p = .009). Post-treatment reduction of MMO mainly occurred in female patients (p < .001) as well as in patients with bilateral fractures (p < .001), high fractures (p = .030) and concomitant mandibular (p = .001) and midfacial fractures (p = .009).

CONCLUSION

Malocclusion seems to be the most frequent long-term complication after open reduction and osteosynthesis of extracapsular mandibular condyle fractures. We suggest ORIF by a transparotid approach to be an appropriate treatment with a low complication rate regarding especially FNP for extracapsular fractures of the mandibular condyle.

Retromandibular Approach and its Different Variations in the Management of Fracture Condyle: Surgical Experience

The management of condylar fractures is a controversial topic in maxillofacial surgery. Surgical treatment is the preferred treatment choice nowadays and the article aims to describe different variations of the retromandibular approach with their surgical outcome based on experience. A total of 15 cases were managed with the retromandibular approach and its different variations. We advocate retromandibular approach for the management of condyle fractures, and among which retromandibular retroparotid and retromandibular anteroparotid provide best accessiblity with less bleeding and minimal risk of injury to the facial nerve.

Prevalence of Frey syndrome following extraoral surgical treatment for mandibular fractures: a systematic review and meta-analysis

Our study aims to estimate the prevalence of Frey syndrome following open reduction and internal fixation (ORIF) for mandibular fractures. Two reviewers independently conducted a systematic literature search in the Medline and Scopus databases. The pooled prevalence with 95% confidence intervals (CI) was estimated, and quality assessment, outlier analysis, and influential analysis were performed. In total, fifteen eligible studies were included in this meta-analysis. One study was identified as critically influential. The overall prevalence of Frey syndrome following extraoral surgical treatment for mandibular fractures was estimated as 0.01% (95%CI 0%-0.7%) with moderate heterogeneity observed between studies. In the meta-regression analysis with continuous variables, no statistically significant association was observed. Despite the relatively low prevalence, the impact of Frey syndrome on affected individuals should not be underestimated. Additional research will provide a more comprehensive understanding of the underlying factors contributing to Frey syndrome, leading to improved preventive measures and treatment strategies. A better grasp of the prevalence and associated risk factors will aid in the development of guidelines to minimize the occurrence of this syndrome.

Prevalence of Frey syndrome following extraoral surgical treatment for mandibular fractures: a systematic review and meta-analysis

Our study aims to estimate the prevalence of Frey syndrome following open reduction and internal fixation (ORIF) for mandibular fractures. Two reviewers independently conducted a systematic literature search in the Medline and Scopus databases. The pooled prevalence with 95% confidence intervals (CI) was estimated, and quality assessment, outlier analysis, and influential analysis were performed. In total, fifteen eligible studies were included in this meta-analysis. One study was identified as critically influential. The overall prevalence of Frey syndrome following extraoral surgical treatment for mandibular fractures was estimated as 0.01% (95%CI 0%-0.7%) with moderate heterogeneity observed between studies. In the meta-regression analysis with continuous variables, no statistically significant association was observed. Despite the relatively low prevalence, the impact of Frey syndrome on affected individuals should not be underestimated. Additional research will provide a more comprehensive understanding of the underlying factors contributing to Frey syndrome, leading to improved preventive measures and treatment strategies. A better grasp of the prevalence and associated risk factors will aid in the development of guidelines to minimize the occurrence of this syndrome.

Treatment for Adult Mandibular Condylar Process Fractures: A Network Meta-Analysis of Randomized Clinical Trials

PURPOSE

Using network meta-analyses (NMA) has become increasingly valuable as it enables the comparison of interventions that have not been directly compared in a clinical trial. To date, there has not been a NMA of randomized clinical trials (RCT) that compares all types of treatments for mandibular condylar process fractures (MCPFs). The aim of this NMA was to compare and rank all the available methods used in the treatment of MCPFs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted in 3 major databases up to January 2023 to retrieve RCTs that compared various closed and open treatment methods for MCPFs. The predictor variable is treatment techniques: arch bars (ABs) + wire maxillomandibular fixation (MMF), rigid MMF with intermaxillary fixation screws, AB + functional therapy with elastic guidance (AB functional treatment), AB rigid MMF/functional treatment, single miniplate, double miniplate, lambda miniplate, rhomboid plate, and trapezoidal miniplate. Postoperative complications were the outcome variables and included occlusion, mobility, and pain, among other things. Risk ratio (RR) and standardized mean difference were calculated. Version 2 of the Cochrane risk-of-bias tool and Grading of Recommendations, Assessment, Development, and Evaluations system were used to determine the certainty of the results.

RESULTS

The NMA included a total of 10,259 patients from 29 RCTs. At ≤6 months, the NMA revealed that the use of 2-miniplates significantly reduced malocclusion compared to rigid MMF (RR = 2.93; confidence interval [CI]: 1.79 to 4.81; very low quality) and functional treatment (RR = 2.36; CI: 1.07 to 5.23; low quality).Further, at ≥6 months, 2-miniplates resulted in significantly lower malocclusion compared to rigid MMF with functional treatment (RR = 3.67; CI: 1.93 to 6.99; very low quality).Trapezoidal plate and AB functional treatment were ranked as the best options in 3-dimensional (3D) plates and closed groups, respectively.3D-miniplates (very low-quality evidence) were ranked as the most effective treatment for reducing postoperative malocclusion and improving mandibular functions after MCPFs, followed closely by double miniplates (moderate quality evidence).

CONCLUSIONS

This NMA found no substantial difference in functional outcomes between using 2-miniplates versus 3D-miniplates to treat MCPFs (low evidence).However, 2-miniplates led to better outcomes than closed treatment (moderate evidence).Additionally, 3D-miniplates produced better outcomes for lateral excursions, protrusive movements, and occlusion than closed treatment at ≤6 months (very low evidence).

"Cervicomastoid Versus Retromandibular Extension of Pre-Auricular Incision in Transmasseteric Anteroparotid Approach for Condylar Fracture Management-a Prospective Study"

Aims

Treating mandibular condylar fractures has always been a matter of debate and controversy. However, there are various approaches, but it is of utmost importance that the surgical procedure must guarantee maximum safety for the facial nerve with best cosmetic outcome and minimizing complications. This prospective study was designed to compare cervicomastoid and retromandibular extension of pre-auricular incision in transmasseteric anteroparotid approach for condylar fractures management.

Patients and Methods

The study was conducted in the Department of Oral and Maxillofacial Surgery, Bapuji Dental College and Hospital, Davangere from November 2015 to May 2017, and a total of 16 condylar fractures were surgically accessed for the management and were divided into two groups, cervicomastoid (Group A) and retromandibular extension (Group B) for evaluating parameters such as to assess the access to condylar region, post-operative edema, cosmetic outcome, time taken to access and facial nerve injury.

Results

Clinically the time taken was significantly less in the cervicomastoid group even though, there was no statistically significant difference regarding access to the fracture site, post-operative edema, facial nerve injury and cosmetic outcome between two groups.

Conclusion

In our opinion the anteroparotid transmasseteric approach is appropriate for surgical management of mandibular condylar fractures as it provides adequate access, ensures safety of the facial nerve and is relatively easy to master. We realize that rather both incisions are good, but cervicomastoid variant is better choice in many aspects one being time taken for the surgery because of better tissue laxity of neck skin when seen in comparison.

Which of 51 Plate Designs Can Most Stably Fixate the Fragments in a Fracture of the Mandibular Condyle Base?

In the surgical treatment of the most common fracture of the mandible, which is a fracture of the condylar base, a great choice of different plate shapes is observed. The aim of this study was to determine which shape gives the greatest fixation stiffness. To ensure homogeneity in comparison, tests were performed on polyurethane models divided at the level of the condylar base fracture and each were fixed with 51 plates. The plates were cut from a 1 mm thick grade 23 titanium sheet. The models were then loaded and the force required for 1 mm of fracture displacement was recorded. It was noted that in addition to osteosynthesis from two simple plates, there were also two dedicated single plates with similar rigidity. Among the large number of described designs of plates, there is considerable variation in terms of the stability of the fixation performed with them. The proposed Mechanical Excellence Factor allows a pre-evaluation of the expected rigidity of fixation with a given plate shape without the need for a loading experiment. The authors expect this to be helpful for surgeons in the application of relevant plates, as well for inventors of new plates for the osteosynthesis of basal fractures in mandibular condyle.

Innsbruck-style Retromandibular Anterior Trans-parotid Approach for Condylar Fractures: A Retrospective Review of 39 Fractures

The retromandibular anterior trans-parotid (RAT) approach and a triangular-positioned double mini-plate osteosynthesis (TDO) technique have been reported from Innsbruck Medical University. This minimally invasive technique involves direct visualization of the condyle and is associated with lower incidence of facial palsy.

Methods

A retrospective review was performed on the RAT approach and TDO technique conducted by a surgeon and team at two hospitals in Tokyo during a period of 3 years and 10 months.

Results

This technique was performed on 35 patients with 39 condylar fractures. Sixty-nine percent of cases were due to accidental fall, 17% to traffic accidents, and 9% to sports. Furthermore, 92% cases were condylar base fractures. Nighty-seven percent of cases achieved good occlusion. The mean maximum mouth opening was 49 ± 1.3 mm. Postoperatively, facial palsy developed in three patients (7.7%), and two of them developed Frey syndrome at approximately 2.5 years postoperatively (5.1%). All patients completely recovered within 3 months postoperatively. One case each of salivary fistula, visible scar, and condylar resorption was found (2.6%). No case of massive bleeding during surgery, hematoma, or TMJ pain after surgery was found.

Conclusion

This technique could achieve good occlusion with low incidence of complications and could contribute to early social reintegration among patients.

The learning curve of transoral condylectomy; a retrospective analysis of 100 consecutive cases of unilateral condylar hyperplasia

In this study, 100 consecutive scheduled transoral condylectomies for unilateral condylar hyperplasia were included. The safety and surgical performances were assessed, using the operating time, conversion rate and complication rate. The conversion rate learning curve was evaluated with a learning curve cumulative summation (LC-CUSUM). The total conversion rate was 8.0%. The LC-CUSUM for conversion signaled at the 53th procedure, indicating sufficient evidence had accumulated that the surgeon had achieved competence. For procedures 54-100, the conversion rate was 4.0%. The operating time for the transoral condylectomy was 41.5 ± 15.3 min; when a conversion was necessary, the operating time was 101.4 ± 28.3 min (p < 0.05). The estimated operating time in the post-learning phase was 37 min, this was reached after approximately 47 procedures. There was 1 major complication of a permanent inferior alveolar nerve hypoesthesia. The complication rate was not significantly decreased after the learning curve. Within the limitations of the study, it seems that transoral condylectomy for UCH is a safe procedure with several advantages over the traditional preauricular approach. Surgeons starting this procedure should be aware of the potential complications and of the learning curve of approximately 53 procedures.

Comparison of three different approaches in treatment of mandibular condylar fractures - Our experience

Background

The principal transfacial routes described to approach condylar process fractures are preauricular, retromandibular, high submandibular, and their various modifications. The selection of a specific surgical approach mainly depends on the level of condylar fracture, displacement/dislocation of the proximal segment and time elapsed from the date of trauma. Not too many studies proclaim a unanimous consensus on "gold standard" approaches for particular levels of fracture.

Aim

This study was conducted with the aim to lay down guidelines for determining the ideal surgical approach for treating different condylar fractures based on different clinical situations.

Methodology

This prospective study was conducted on 60 patients that underwent open reduction internal fixation of condylar fractures according to preset study design. Inclusion criteria were fracture displacement more than 10 degrees, dislocation, shortening of ramal height more than 2 mm. Patients having maxillofacial fractures other than mandible and condylar fractures in edentulous patients were excluded from this study.

Results

The risk of facial nerve injury was more in endaural group and parotid fistula was more evident in retromandibular subparotid group but there was no statistical difference between the groups. The surgical scar was inconspicuous in all three groups. Excellent results were achieved in the other parameters such as mouth opening, range of motion, bite force, and occlusion with all the three approaches. Postoperative CT scan showed satisfactory anatomical reduction.

Conclusion

This study concludes that the decision-making on the approach to be selected for any particular condylar fracture depends on the level of fracture, presence of fracture dislocation, and time elapsed from the date of trauma.

Infinitesimal Periangular Pterygomasseteric Transectioning Approach for the Base Fractures of the Mandibular Condyle: A Technical Note and Quality of Life Outcome

Purpose Infinitesimal Periangular Pterygomasseteric Transectioning Approach (IPPTA) is a minimal access surgical approach utilized for the management of base fractures of the mandibular condyle. The aim of the study was to evaluate and report the long-term post-operative functional outcome using this surgical access approach. Materials and method A prospective clinical study involving 20 patients was undertaken to evaluate the post-operative functional and aesthetic outcome for the patients that underwent surgery for base fractures of the mandibular condyle using IPPTA. The various parameters assessed were wound healing, marginal mandibular nerve injury, diet intake, mandibular function, and any other complications at twelfth post-operative month. Results IPPTA provided adequate exposure to the condylar base fracture for open reduction and internal fixation (ORIF) and was found to have an uneventful post-operative recovery phase in terms of functional and aesthetic outcomes. Conclusion IPPTA involves utilizing a smaller incision and provides adequate exposure to the condylar base region for ORIF to establish a satisfactory form and function with a predictable outcome.

Modified high-submandibular appraoch for open reduction and internal fixation of condylar fracture: case series report

OBJECTIVES

Recently a modified high-submandibular approach (HSMA) has been introduced for treatment of condylar fracture. This approach involves an incision line close to the mandibular angle and transmasseteric transection, leading to a low incidence of facial palsy and allowing good visualization of the condyle area, especially the condylar neck and subcondyle positions. This study reports several cases managed with this modified HSMA technique for treating condylar fractures.

MATERIALS AND METHODS

Six cases of condylar fractures treated with modified HSMA technique were reviewed.

RESULTS

Three unilateral subcondylar fracture, 1 bilateral subcondylar fracture, 1 unilateral condylar neck fracture, 1 unlateral simultaneous condylar neck and subcondylar fracture cases were reviewed. All the cases were successfully treated without any major complication.

CONCLUSION

Reduction, fixation, and osteosynthesis of condylar fractures via the modified HSMA technique enabled effective and stable treatment outcomes. Therefore, the described approach can be used especially for subcondylar and condylar neck fractures with minimal complications.

Preauricular anteroparotid transmasseteric approach of the mandibular condyle: The natural evolution after cervical dissections? An anatomical feasibility study

The purpose of this study was to evaluate the reliability and reproducibility of a novel approach for base and neck fractures of the mandible. An anatomical study was conducted on 22 given to Science subjects. A rhytidectomy-like approach was performed, followed by a transmasseteric anteroparotid dissection. Measures were taken of the incision length and bone exposure at every step. The identification of a ramus of the facial nerve during dissection was noted. The subjects were classified according to their facial adiposity. A correlation coefficient was measured between incision length and bone exposure as well as morphotype and bone exposure. Statistical analysis was carried out using the Pearson method for linear correlation, and Chi2 test for further analysis. Adequate condylar exposure was always achieved in the area of interest (i.e. in the main localization of base and neck fractures). There was no correlation between the length of the cranial cutaneous backcut and the bone exposure horizontally (p = 0.3296) or vertically (p = 0.8382). There was no correlation between the total length of the incision and the bone exposure horizontally (p = 0.5171) or vertically (p = 0.8404). There was a significant correlation between the subjects' facial adiposity and the bone exposure horizontally and vertically (p&lt;0.005). This approach allowed adequate bone exposure to the mandible base and neck, with a possible 90° angulation of instruments for optimal bone fixation. The incidence of facial nerve rami identification during dissection was similar to other approaches. The scarring was hidden. These results allowed us to propose this approach in a clinical study.

Endoscopic-Assisted Intraoral Approach for Osteosynthesis of Mandibular Subcondylar Fractures

The aim of this study is to follow-up and evaluate the treatment result of mandibular subcondylar (MSC) fractures by osteosynthesis via endoscopy-assisted intraoral approach.

Complications of the Transmasseteric Anteroparotid Approach for Subcondylar Fractures: A Retrospective Study

Study Design

A retrospective analysis of patients with subcondylar fractures treated via a transmasseteric anteroparotid approach by the Oral and Maxillofacial Department at the University of Oklahoma.

Objective

The goal of this study was to evaluate complications, morbidity, and safety with the transmasseteric anteroparotid approach for treatment of subcondylar fractures, and compare it to other findings previously reported in the literature.

Methods

A retrospective study was conducted that consisted of 23 surgically treated patients in the past 2 years for subcondylar fractures. Only patients with pre-operative malocclusion and who underwent open reduction with internal fixation with the transmasseteric anteroparotid (TMAP) approach were included. Exclusion criteria included 1) patients treated with closed reduction 2) patients who failed the minimum of 1, 3, and 6-week post-operative visits. The examined parameters were the degree of mouth opening, occlusal relationship, facial nerve function, incidence of salivary fistula and results of imaging studies.

Results

20 of the surgically treated patients met the inclusion criteria. Two patients were excluded due to poor post-operative follow up and 1 was a revision of an attempted closed reduction by an outside surgeon that presented with pre-existing complications. There were no cases of temporary or permanent facial nerve paralysis reported. There were 3 salivary fistulas and 2 sialoceles, which were managed conservatively and resolved within 2 weeks, and 2 cases of inadequate post-surgical maximal incisal opening (<40 mm) were observed.

Conclusion

The transmasseteric anteroparotid approach is a safe approach for open reduction and internal fixation of low condylar neck and subcondylar fractures, and it has minimal complications.

Comparative Evaluation of Modified Tragus Edge Approach and Retromandibular Approach to Mid- or Low-Level Mandibular Condylar Fractures

Objectives

To compare and evaluate the modified tragus edge approach (MTEA) with retromandibular approach for surgical access to mid-level or low-level mandibular condylar fractures.

Materials and Methods

This study comprised of 22 patients with mid-level or low-level condylar fracture. Patients with clinical and radiological evidence of mid-level or low-level condylar fracture are included only in this study. Patients were randomly divided into two groups: group A includes 11 patients, in which modified tragus edge approach was used, and group B includes 11 patients treated with retromandibular approach. Patients were evaluated clinically after first week, second week, fourth week, third month, and sixth month radiographically.

Results

The mean age of the study subjects in group A was 32.45 ± 8.98 years, while in group B, the mean age was 26.91 ± 5.79 years. Post-operatively, no significant difference was seen in relation to pain, occlusal relationship, mouth opening, and deviation of jaw during opening and closing movements. In terms of post-operative complication, only significant difference found between two groups is post-operative scar visibility, which is higher in retromandibular incision group as compared to MTEA.

Conclusion

Thus, we can conclude that MTEA provides ease of operation as a good exposure of mandibular mid- or low-level condylar fracture as retromandibular approach but with less visibility of post-operative scar as compared to retromandibular approach.

Modified Blair Approach for the Treatment of Mandibular Condyle Fractures

PURPOSE

The management of fractures of the condyle of the mandible has been a topic of debate and still no consensus exists in the literature about the most appropriate approach. The objective of this study was to evaluate the efficacy and safety of the modified Blair approach for the open reduction and internal fixation of mandibular condyle fractures.

METHODS

A retrospective study was conducted on 18 patients with 20 mandibular condyle fractures from 2014 to 2020. All patients were treated surgically using the modified Blair approach. Postoperative occlusion status and mouth opening were assessed for treatment outcomes. Also, the rate of complications such as facial nerve paralysis, wound infection, hematoma, salivary fistula, Frey syndrome, and greater auricular nerve paraeesthesia evaluated.

RESULTS

Seventeen out of 18 patients (94.4%) achieved their original pretraumatic occlusion after the surgery. One patient (5.5%) had postoperative occlusal interference due to premature dental contact. The maximal postoperative interincisal distance was measured with a range between 33 and 41 mm (mean 37.6 mm). One patient (5.6%) had transient facial nerve palsy. Also, salivary fistula developed in 1 (5.6%) patient in the postoperative period.

CONCLUSION

The results of this study revealed that the modified Blair approach provides satisfactory clinical outcomes with low complication rates and may offer an alternative, safe, and effective method for open reduction and internal fixation of mandibular condyle fracture.

Management of Mandibular Subcondylar Fracture Through an Intraoral Approach Using a Trans-Buccal Trocar With Ramus Buccal Decortication

PURPOSE

The aim of this study was to review retrospectively the functional recoveries of subcondylar fracture patients that underwent open reduction surgery using an extraoral approach or an intraoral approach using a trans-buccal trocar and involving ramus buccal decortication.

MATERIALS AND METHODS

Of 47 patients with mandibular condyle fracture who visited Pusan National University Dental Hospital Department of Oral and Maxillofacial Surgery between May 2015 and November 2020, 38 patients underwent open reduction and were classified according to the surgical method used. Preauricular, submandibular, and retro-mandibular approaches were all classified as extraoral approaches condyle fractures were classified as described by Spiessl and Schroll (1972). Distances between bone fragments on panorama radiographs before and after surgery were measured.

RESULTS

Thirty-eight patients were included in this study, 9 patients received subcondylar fracture surgery. Open reduction surgery using an extraoral approach had a greater mean operation time than the intraoral approach using a trocar. Of the 17 patients treated with an intraoral approach, the average distance between bone fragments right after surgery was 1.27 ± 1.41 mm, which was significantly greater than that of the extraoral approach (0.72 ± 0.35 mm).

CONCLUSIONS

Favorable results can be obtained by mandibular condylar fracture surgery through an intraoral approach using a trans-buccal trocar with ramus buccal decortication. This technique minimizes scarring, secures accessibility using a trocar, and sufficiently secures the field of view through buccal cortical bone reduction.

Mini - Retromandibular access to sub condylar mandibular fractures - Our experience

Condylar fractures alone accounts to about 25% to 40% of all the fractures of mandible. Management of condylar fractures has always been a controversy. Nowadays there has been more emphasis on open reduction of condylar fractures by the surgeons.The reasons could be the result of complications of closed reduction where the patient may not be able to masticate properly and deviation still present thereby the structural and functional loss forcing the surgeons' choice to open up. The anterior parotid approach has lesser risk of injury to parotid gland and also to facial nerve we attempted to use mini retro mandibular access for such fractures. So the aim was to explore the feasibility of the mini retro mandibular approach to sub condylar fractures. The patients reported to the department of oral and maxillofacial surgery department clinically and radio logically diagnosed and treated for condylar fractures were included. The maximal mouth opening, protrusive and lateral excursive movements, midline orientation with opposing arch, scar visibility, sialocele and facial nerve weakness were all recorded post operatively and compared with pre-operative recording. The mini retro mandibular access with anterior parotid transmessetric approach to sub condylar fractures can be the choice for the surgical management of sub condylar fractures which is absolutely easy, reliable, with less visible scar and with less chances of landing in facial nerve complications.

A comparative evaluation of retromandibular versus Modified Risdon approach in surgical treatment of condylar fracture

The purpose of this study was aimed to compare the efficiency and safety of retromandibular versus modified Risdon approach using periangular incision for open reduction and internal fixation of low subcondylar mandibular fracture. Open reduction and internal fixation with different plating systems were utilized via retromandibular approach (group I) and via modified Risdon approach with periangular incision (group II). Twenty four (n= 24) condylar fractures in 21 adult patients were divided randomly into two equal groups (12 each) according to the cutaneous incision (approach) utilized. The evaluation score for scarring in group I it was excellent in 9 patients, good in 2 patients and acceptable in only one patient (Mean 2.4 ± SD 3.38). While in group II was excellent in 10 patients and good in 2 patients (Mean 2.4 ± SD 3.87) and the p value was 0.591. Symptoms of transient facial nerve weakness were noted in only 3 patients in group I with slight to moderate dysfunction (Mean 2 ± SD 3.21), while only one patient had facial nerve weakness in group II with House - Brackman score of 2 immediate postoperatively and this got resolved in 6 weeks (Mean 2 ± SD 4.04) and the p value was 0.00022. Within the limitations of the study it seems that a modified Risdon approach using periangular incision for reduction and fixation of low subcondylar fracture should be preferred whenever possible because it yields better outcomes.

Unilateral Condylar Fracture with Review of Treatment Modalities in 30 Cases - An Evaluative Study

Introduction:

The treatment of subcondylar mandible fractures is a topic of debate and can be variable even though these fractures are commonly seen. The present study aimed at evaluation of various treatment modalities for unilateral condylar fracture in adults.

Materials and Methods:

Thirty patients with unilateral condylar fractures between the age of 18 and 60 years were evaluated. Treatment protocol included closed reduction for 15 patients and open reduction for 15 patients.

Results:

Assessment was done functionally for maximum interincisal mouth opening, deviation on maximum interincisal mouth opening, occlusion and facial nerve function, and radiologically for ramus height shortening. In general, there were no statistically significant differences between closed and open methods.

Discussion:

Both the treatment options for condylar fractures of the mandible yielded acceptable results. Closed treatment appears to be a safe and appropriate modality for most unilateral condylar fractures. Although the open group, in general, showed similar outcomes, this treatment should be reserved for limited indications. The present study has confirmed that both treatment options can yield acceptable results. On clinical examination, there was no significant difference in mouth opening measures, the incidence of occlusal disturbances or in the degree of pain perception.

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.

Evaluation of 3D Trapezoidal Plates in Open Reduction and Internal Fixation of Subcondylar Fractures of Mandible: A Clinical Trial

Background  Fractures of the mandibular condyle are common and account for 25% to 50% of all fractures of the mandible. Various methods exist for open reduction and internal fixation (ORIF) of condylar fractures. This study was done to explore three-dimensional (3D) plates as a viable option. Aim  This study aims to evaluate the effectiveness of 3D trapezoidal plates in open reduction and internal fixation of subcondylar fractures. Materials and methodology This was a non-randomized clinical trial conducted on 20 patients who reported at the Department of Oral and Maxillofacial Surgery, Tamil Nadu Government Dental College and Hospital, Chennai, India. The ORIF was done under general anesthesia. A retromandibular transmasseteric approach was used to expose the fracture site, and the fracture was stabilized using 3D titanium trapezoidal plates. Parameters, such as mouth opening, mandibular deviation, occlusion, surgical accessibility, fracture reduction, adaptability, the difference in ramal height, angulation of the fractured condyle, operative time, facial nerve weakness, implant failure, complications, and scar formation were assessed. Statistical analysis was done using Statistical Package for Social Sciences (SPSS), version 21 (IBM SPSS Statistics for Windows, Armonk, NY). Results  There was an improvement in mouth opening and occlusion in the immediate postoperative period. The surgical accessibility ranged from good to excellent. The fracture reduction was excellent in 60% of patients and good in 40%. In one patient, there was a transient weakness of the marginal mandibular nerve which recovered by three months. Another patient had a wound infection that subsided within the first postoperative week. None of the patients had a device failure during the six-month follow-up period. Conclusion  The trapezoidal 3D plates could be considered as a viable option for treating subcondylar fractures of the mandible in terms of surgical accessibility, stability, ease of device placement, stability of reduced fracture, reduced osteosynthesis material requirement, and minimal damage to the surrounding tissues.

Prediction of Conservative Treatment Failure for Isolated Unilateral Mandibular Condylar Fractures Using Quantitative Measures: Suggestion of Indications for Intervention

BACKGROUND

Interest in the treatment of mandibular condyle fracture in cases of maxillofacial trauma has been a huge concern for decades because of a diversity of opinions on the topic and the relatively few studies conducted on individuals treated by physiotherapy or rehabilitation with or without intermaxillary fixation (IMF).

METHODS

We measured fracture gaps between bone ends over an 8-year period from 2012 to 2019. The study cohort was composed of only conservatively treated patients. This retrospective study was conducted to identify factors that influence treatment failure by comparing a functional treatment (physiotherapy) group with an IMF group in terms of fracture gaps and other variables. In addition, an algorithm was devised to enable clinicians to determine promptly whether IMF is needed for mandibular condylar fractures.

RESULTS

Significant correlations were observed between several parameters and malocclusion. Multiple regression analysis resulted in the following coefficients: 0.072 for fracture gap (P = 0.006) and 0.006 for age (P < 0.05) in functional treatment group. However, in the IMF group, correlations with malocclusion were 0.063 for fracture gap (P = 0.000) and 0.003 for age (P = 0.083).

CONCLUSIONS

We proposed a diagnostic algorithm for isolated unilateral mandibular condyle fractures that provides guidance regarding surgical correction. If indications for surgical correction, as regards anatomical location, fracture level, fracture gap between bone ends, and patient cooperability, are not satisfied, clinicians should select IMF or functional treatment (rehabilitation). If the fracture gap is less than 6 mm and the patient is cooperative, functional rehabilitation would be more suitable than IMF.

Management of Medially Displaced Sub-Condylar Mandibular Fractures in Pediatric Population Using Novel Atraumatic Approach

ABSTRACT

The appropriate treatment of pediatric mandibular condyle fractures is subject to much debate and concern among surgeons, with improper treatment potentially resulting in a number of adverse outcomes. Such outcomes include the disruption of mandible growth, decreased posterior facial height, facial asymmetry, and temporomandibular joint ankylosis. Several surgical and nonsurgical approaches to these fractures have been described in the literature; however, each one carries its own risk of various complications. In this study, the authors illustrate a new atraumatic approach for mild to moderately displaced subcondylar fractures, with least possible complications and unexpected outcomes. In this study, 6 patients (2 female and 4 male) with unilateral medially displaced condylar base and neck fractures, angulated between 30 and 45 degrees, were treated using a novel intraoral approach. The follow-up period varied from 12 to 18 months. All patients achieved normal occlusion and had painless functioning of the temporomandibular joint with proper mouth opening (>35 mm) without any recurrence at long term follow up. This minimally invasive approach could eliminate the possibility of major complications and be considered a safe and feasible surgical technique for certain cases of pediatric mandibular condyle fracture.

Does Surgical Specialty Impact Mandibular Fracture Outcomes?

PURPOSE

Maxillofacial trauma is treated by two medical specialties, plastic surgery (PRS) and otolaryngology (ENT). Differences in training exposure and practice patterns exist between specialties, but their respective outcomes have never been compared.

METHODS

Mandible fracture data were reviewed from the National Surgical Quality Improvement Program from 2005 to 2016. Demographics variables, repair types, and adverse outcomes were compared between PRS and ENT.

RESULTS

From 2005 to 2016, one thousand two hundred eighty-two cases were identified with 756 cases managed by ENT and 526 cases managed by PRS. Mean patient age was 34.6 years for both specialties (P = 0.95). Patient demographics between both cohorts were not statistically different except for higher rates of hypertension among ENT patients (10.2% for ENT versus 6.7% for PRS, P = 0.027) and higher rates of smoking history among PRS patients (46.8% versus 52.3%, P = 0.055). Mean operative time (131.3 versus 124.0 min, P = 0.090) had a trend toward being longer for ENT and mean length of stay (1.3 versus 2.0, P = 0.002) was significantly longer for PRS. Despite a greater proportion of high ASA class patients in the ENT group (P = 0.012) and patients with dirty/infected wounds in the PRS group (P = 0.013), there were no significant differences in 30-day readmission rates, 30-day reoperation rates, or wound infection rates.

CONCLUSIONS

No significant differences in 30-day readmission rates, reoperation rates, or wound infection rates for mandible fracture management exist between specialties. Despite differences in training between PRS and ENT, both specialties have comparable perioperative outcomes for mandible fracture management.

Choice of Screws for Fixation of Mandibular Condyle Fractures Guided by Anthropometric Data

Open reduction and internal fixation (ORIF) is becoming increasingly common in treatment of the condylar process, including mandible head fractures. This approach significantly improves the results in terms of anatomical reduction of bone fragments, and shortens the treatment time, allowing for early functional recovery. The success of ORIF is largely determined by the stability of the osteosynthesis. The stabilization effect depends on the screw type and length of the plate used, in addition to the diameter and length of the screws used. The aim of this study was to determine the largest possible screw length that can be used in ORIF of the mandibular condyle considering the variable bone thickness. A total of 500 condyles were examined using computer tomography (CT)-based 3D models in Caucasians. For all models, three measurements were made in the frontal projection in places typical for the stabilization of osteosynthesis plates in the fractures of the condylar process: the base, the top, and the sigmoid notch. In addition, one measurement of the mandible head was made in the place of the greatest width. The results showed that 8 mm screws should be used in the region of the condylar base as the longest anatomically justified screw, whereas in the area of a sigmoid notch only 1.5–2 mm screws should be used. Measurements in the area of the neck top revealed statistically significant differences in the measurements between the sex of patients, with average differences below 1 mm (p < 0.05). In this area, the maximal length of the screw was found to be 10 mm. In mandibular head fractures, the use of long screws is extremely important due to the desired effect of fragment compression. Statistically significant differences were found in the measurement results between women and men. The maximal screw length for bicortical fixation was found to be 22 mm in men and 20 mm in women. In post-traumatic patients, the ability to obtain a clear measurement is often limited by a deformed anatomy. Taking into account the fact that the fracture stability is influenced by both the plate length and the length of the fixation screws, an assessment of the standard measurement values in a cohort group will improve the quality of the surgical fixations of the fractures.

Retromandibular vein position and course patterns in relation to mandible: anatomical morphologies requiring particular vigilance during sagittal split ramus osteotomy

Major bleeding associated with sagittal split ramus osteotomy (SSRO) involves vessels such as the inferior alveolar, facial, and maxillary arteries and veins, and the retromandibular vein (RMV). The present study aimed to clarify and classify the three-dimensional variations in RMV position and course direction in relation to the mandible. Specimens comprised a total of 15 scientific cadavers, and the relationship between RMV and the mandible lateral and posterior views was observed. We identified 3 patterns on the lateral view, the mean distance between the RMV and the posterior border of the ramus was 3.9 mm at the height of the lingula. A total of five course patterns were identified on the posterior view. In no course pattern, the RMV inferior to the lingula was lateral to its position superior to the lingual. The present findings suggest that it may be possible to predict correlations with intraoperative bleeding risk. Further study is planned using contrast computed tomography in patients with jaw deformity for skeletal classification.

Analysis between Retromandibular and Periangular Transmasseteric Approach for Fixation of Condylar Fracture - A Prospective Study

Introduction:

Condylar fractures make up for an average of 17.5%–52% of all mandibular fractures. The aim of the present study was to compare the ease, success, and complications between retromandibular and periangular transmasseteric approaches when used for open reduction and internal fixation of condylar fractures.

Materials and Methods:

A total 20 cases with condylar fracture, ten each for retromandibular and periangular transmasseteric approach, were included in the study. Patients were evaluated at 1 week, 1 month, 3 months, and 6 months. Postoperative occlusion, maximum mouth opening, range of movement, facial nerve function, visibility, convenience of plating, and time taken for exposure, fixation, and closure were recorded. Incidence of complications such as wound dehiscence, wound infection, hematoma, sialocele formation, Frey's syndrome, and hypertrophic scars were also evaluated.

Results:

The mean exposure time in the retromandibular approach was 10 min 31 s and 9 min 17 s in the periangular transmasseteric approach. The incidence of facial nerve injury was 2 of 10 patients in the retromandibular group and 3 of 10 patients in the periangular transmasseteric group, all of which resolved within 6 months. The incidence of sialocoele was 2 of 10 in the retromandibular group. The time taken for exposure of the fracture site was statistically significant between the two approaches (P = 0.048) with longer time required for retromandibular approach.

Discussion:

It can be summarized that both the approaches are comparable and well suited for surgical management of condylar fractures. It was observed that in displaced condylar neck fractures, greater difficulty was experienced in the periangular transmasseteric approach than the retromandibular approach.

Retromandibular transparotid approach for subcondylar mandibular fracture: A retrospective study

INTRODUCTION

The retromandibular transparotid approach provides the shortest and the most direct access to mandibular sub-condylar fractures. However, this approach is less preferred due to the fear of facial nerve injury. The aim of this study was to evaluate the safety and morbidity of the retromandibular transparotid approach for open reduction and internal fixation of sub-condylar mandibular fractures.

METHODS

A retrospective cohort study of 29 patients with 35 sub-condylar mandibular fractures who underwent open reduction and internal fixation through the retromandibular transparotid approach was conducted. The primary study variable was facial nerve palsy, whereas the secondary variables were infection, sialocele, salivary fistula, stability of the fractured segments, post-operative malocclusion, Frey's syndrome, and unesthetic scar. All patients were followed up for 6 months. Predictor variables included age, gender, side, location, displacement, etiology, concomitant maxillofacial fractures, and healing status. Fisher's exact test was calculated to find the association between primary variables and predictor variables.

RESULT

Out of 35 sub-condylar fractures (29 patients; 23 male, 6 female), four (11.42%) developed transient facial nerve palsy. Fractures at the condylar neck level (P = .045) and with displacement (P = .026) were significantly associated with the development of facial nerve palsy. Four patients (13.8%) developed slight malocclusion, two had surgical site infections, two developed sialoceles, and one had a salivary fistula.

CONCLUSION

The retromandibular transparotid approach is safe and effective with rare major complications in the management of sub-condylar fractures of the mandible. Condylar neck fractures and displaced fractured segments are associated with an increased risk of development of facial nerve palsy.

Algorithm for Management of Mandibular Condylar Base Fractures

Supplemental Digital Content is available in the text.

Background:

Increasing evidence suggests that open reduction and internal fixation of condylar base fractures in adults results in improved outcomes in regard to interincisal opening, jaw movement, pain, and malocclusion. However, most of the condylar fractures are managed by maxillomandibular fixation alone due to the need for specialized training and equipment. Our aim was to present an algorithm for condylar base fractures to simplify surgical management.

Methods:

A retrospective review was performed of patients (n = 22) with condylar base fractures treated from 2016 to 2020. Patients who presented with operative fractures that require open treatment underwent 1 of 2 different techniques depending on the fracture type: a preauricular approach with a transoral approach if the condyle was dislocated (n = 2) or a transoral only approach (n = 20) in nondislocated cases. Operative time, occlusion, range of motion, and postoperative complications were assessed.

Results:

Condylar base fractures were combined with other mandibular fractures in 16 of 22 patients. Patients with condylar dislocation were managed with a preauricular approach with a secondary transoral incision (n = 2, median 147 minutes). Those without dislocation were treated with a transoral approach (n = 20, median 159 minutes). Most patients were restored to their preoperative occlusion without long-term complications.

Conclusions:

We present a simplified algorithm for treating condylar base fractures. Our case series suggests that reduction in operative time and clinical success can be achieved with open reduction and internal fixation using a transoral approach alone or in combination with a preauricular approach for dislocated fractures.

Clinico-anatomical classification of the processus condylaris mandibulae for traumatological purposes

Mandible condyle fracture has been reported to constitute 9-45 % (Asprino and Consani, 2006), 14.1 % (Bataineh, 1998), 25-50 % (Silvennoinen, Iizuka, 1992), 32 % (Chrcanovic et al., 2004), and 38 % (Brasileiro and Passeri, 2006) of all mandible fractures (Kozakiewicz and Swiniarski, 2013). Small bone segments, limited available space for application of the fixation material and limited visibility of the operative field are common difficulties. To guarantee satisfactory treatment effects, anatomical reduction and proper fracture stability are necessary. The use of 3-4 screws in the upper section (proximal segment) provides adequate immobilization, which can be easily achieved when the condyle is low and wide. However, if the condyle is slender, it is not technically possible to fix 2 plates and 4 screws for osteosynthesis. Selection of the appropriate fixative material that will provide adequate rigidity during the healing period while simultaneously allowing proper construction of the lateral silhouette of the processus condylaris mandibulae to fix the plate remains a key consideration. The aim of this study was to evaluate clinico-anatomical classification of the condyle of mandible posture for traumatological purposes. Five hundred computer tomography virtual models were created, from which 11 measurements were made, and 2 indexes were calculated. Assessment of types based on the ratio of the condyle height index revealed a dichotomous division into high and short condyles. Statistically associated with the division, the Width_neck_basal (the width of the bone at the level of semilunar notch measured by a frontal projection perpendicular to line "A", as described by Neff (Neff et al., 2014)) measurement allowed the creation of the following clinico-anatomical classification: -slender-type condyles have a Width_neck_basal in the range of 4-8.5mm; -squad-type condyles have a Width_neck_basal in the range of 11.5-19.5mm. Patients with a Width_neck_basal value in the 8.5-11.5mm range cannot be classified using this method, and a different method to assess the lateral condylar silhouette must be used. The proposed clinic-anatomical classification method avoids the problems associated with incorrect osteosynthesis plate selection. Assignment to a group can be obtained by making one measurement (the Width_neck_basal). In that way, the optimal fixing material can be selected by the surgeon before the operation commences, with great intraoperation time savings.

Evaluation of Open Reduction and Internal Fixation of Mandibular Condyle Fracture by Intraoperative Cone-Beam Computed Tomography in a Hybrid Operating Room

Condylar fractures are the most common fractures of the mandible, and treatment of mandibular condylar fractures by maxillofacial surgeons is a very important procedure. However, the surgical approaches have anatomical limitations. Therefore, it is difficult to evaluate the reduction achieved in open reduction and internal fixation because of the uncertainty in securing a sufficient operative field. As a potential solution, the authors evaluated the benefits of intraoperative cone-beam computed tomography (CBCT) with high image quality performed in a hybrid operating room. Intraoperative CBCT is easy to perform in a hybrid operating room, and it is possible to quickly evaluate high-quality CT images, including 3D images. Because the state of reduction of mandibular condylar fractures also affects the prognosis of treatment, more precise reduction and fixation should improve prognoses. The use of CBCT in a hybrid operating room also avoids re-operation, and patients benefit from minimum invasive surgery. Intraoperative CBCT is a very useful strategy for evaluation of mandibular condylar fracture surgical treatment.

Clinical Assessment of Retromandibular Antero-Parotid Approach for Reduction of Mandibular Subcondylar Fractures: Report of 60 Cases and Review of the Literature

This study assessed the efficacy of the retromandibular antero-parotid approach for open reduction and internal fixation (ORIF) of subcondylar fractures. Sixty patients with the mean age of 31.03 years underwent surgical reduction with a 20–25mm incision in the retromandibular area with an antero-parotid transmasseteric approach. All patients were followed between 6 to 12 months. At the end of the first week, six patients exhibited postoperative malocclusion. At the next visits, all patients had optimal occlusion. Maximal interincisal opening (MIO) of 56 patients (93.3%) was >37mm, and only four patients (6.7%) had MIO<37mm. In three patients (5%), weakness of the buccal branch of the facial nerve was noticed postoperatively. No salivary gland complications were seen. The surgical scar was hardly noticeable. Retromandibular access with transmasseteric antero-parotid approach is the technique of choice for treatment of high- and low-level subcondylar fractures with adequate visibility and direct access to the condylar area.

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.

The Retromandibular Transparotid Approach for Reduction and Internal Fixation of Mandibular Condylar Fractures

Introduction:

The retromandibular transparotid approach is most useful for condylar and subcondylar fractures and provides the best access to the joint and ascending ramus. The study aims at evaluating the ease of access and outcomes encountered on using the retromandibular transparotid approach to access the fracture site for the open reduction and internal fixation (ORIF) of condylar and sub-condylar fractures.

Materials and Methods:

An observational clinical study was carried out among 10 patients with unilateral and bilateral condylar fracture requiring ORIF. Maximal interincisal mouth opening, facial swelling, occlusal discrepancy, facial nerve injury, scar formation, and acceptability and complications including wound dehiscence, infection, and sialocele/salivary fistula were assessed and measured preoperatively and postoperatively.

Results:

There was a notable improvement in mouth opening and facial nerve weakness. Postoperative intermaxillary fixation was done with selective patients who had a discrepancy in their occlusion. Preoperatively, swelling was present in four patients (40%) out of 10 patients studied. There was no incidence of sialocele/salivary fistula in any of the cases studied.

Conclusion:

Retromandibular transparotid incision is technique sensitive and thorough knowledge about the retromandibular area is must for good results and minimal morbidity. The cosmetic results are good in this approach, as well as the facial nerve injury were less in this without any permanent damages.