The role of open reduction and internal fixation in unilateral fractures of the mandibular condyle: a prospective study

Evaluation of grafts fixation techniques for temporomandibular joint reconstruction with medial femoral condyle flap: A numerical study

Reconstruction for large-scale temporomandibular joint (TMJ) defects can be challenging. Previously, we utilized the medial femoral condyle (MFC) flap for TMJ reconstruction. However, the optimal fixation method remains uncertain. In this study, finite element analysis was used to study the effects of three different fixation types of bone graft: overlap type, bevel type, and flush type. Models of different fixation types of MFC flap were reconstructed from CT images. A standard internal fixation model for extracapsular condylar fracture was also included as a control. Displacement of bone graft, deformation of plates and screws, and stress distribution of plates, screws, and cortical and cancellous of the bone graft were analyzed by finite element analysis to investigate their biomechanical features. The displacement of the bone graft and deformation of plates and screws in three different fixation types showed no significant difference. The overlap type and flush type of fixation displayed the lowest and highest stress respectively. All three fixation types could satisfy the mechanical requirement and face no risk of breakage and the major displacement of the MFC bone graft. These results provide insights into the optimal fixation approach for MFC bone grafts, offering valuable guidance and reference for clinical application.

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.

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.

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.

Treatment of pediatric bilateral condylar fractures: A comprehensive analysis

Pediatric bilateral condylar fractures (PBCF) is a rare clinical pathology, where the management is carried out with both conservative and surgical approaches. The purpose of this study was to analyze and compare these two treatment approaches and their associated long term complications in PBCF. An extensive literature review- through the search of online databases- was conducted to survey, collect, analyze and compare the reported outcomes of different treatment modalities for PBCF. The number of studies presenting PBCF case reports was 16, while the number of such retrospective studies included here was 19. Analyses of these studies revealed that the conservative treatment is preferred in PBCF patients younger than 12 years of age. Moreover, a composite approach where the open reduction and internal fixation (ORIF) is carried out for one side while the intermaxillary fixation (IMF) for the contralateral side is frequently reported for the management of PBCF cases; this approach appears effective in improving daily functioning of temporomandibular joint and reducing long term complications. Performing ORIF for one side while IMF for the contralateral side seems the most common treatment approach in PBCF. This study may help in rapid decision making for treatment selection of PBCF patients while minimizing the risk for late complications.

Evaluation of internal fixation techniques for extracapsular fracture: A finite element analysis and comparison

BACKGROUND AND OBJECTIVES

This study explored the optimal plates and screws fixation for extracapsular fracture by finite element analysis, and provided a biomechanical basis for clinical treatment.

METHODS

Four extracapsular fixation models were built and evaluated: A. One single straight four-hole plate with two bi-cortical screws on both sides and two mono-cortical screws in the middle; B. One single straight four-hole plate with four bi-cortical screws; C. Two straight four-hole plates, each with two bi-cortical screws on both sides and two mono-cortical screws in the middle; D. One L-shape four-hole plate in the back and one straight four-hole plate in the front, each with two bi-cortical screws on both sides and two mono-cortical screws in the middle. Displacements of fractured bone blocks and stress of plates, screws, cortical and cancellous bone and the deformation of plates were analyzed by finite element analysis to investigate their stability in clinical using.

RESULTS

Groups A and B showed larger displacements of the fractured bone block, greater deformation of plates and higher risk of the plate breakage during masticatory motion. Groups C and D exhibited the minimum displacements of the fractured bone block, the stress distribution within the safe range and less deformation of the plates. In addition, double plates fixation and bi-cortical screws exceeded single plate fixation and mono-cortical screws in stability, respectively, while an L-shape plate exhibited no significant differences in the stress dispersion and the displacement reduction.

CONCLUSIONS

Double plates fixation of the extracapsular condylar fracture was a safe and stable way and bi-cortical screws should be selected as far as possible.

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.

Open Reduction and Internal Fixation Versus Closed Reduction and Maxillomandibular Fixation of Condylar Fractures of the Mandible: A Prospective Study

Background

The choice of surgical versus nonsurgical treatment for fractures of the condylar process has its own limitations and remains a controversial issue. Improved knowledge of anatomy, technique, and technology combined with adequate experience with careful planning of surgical technique can avoid all the possible complications.

Aim

To compare open reduction and internal fixation with closed reduction and maxillomandibular fixation in the management of condylar fractures.

Materials and method

A prospective study was carried out among 22 patients who had minimally displaced or displaced condylar fractures. The patients were divided into two groups of 11 each: group A patients treated with open reduction and rigid internal fixation and group B patients treated with closed reduction and maxillomandibular fixation. Follow-up examinations were performed at one week, one month, three months, and six months postoperatively.

Results

Preauricular pain was significantly decreased (p < 0.001) in both groups postoperatively but more significantly decreased in the open reduction group. There was a significant improvement in the mouth opening at every follow-up to a maximum mean of 37.36 mm in group A and a mean of 33.64 mm in group B. Significantly more improvement in protrusive and lateral movements and reduced deviation on mouth opening at every follow up was observed in the open reduction group.

Conclusion

Both the treatment options for condylar fractures of the mandible yielded acceptable results with significant clinical differences in terms of occlusion, mouth opening, functional movements, and pain among patients with open reduction.

Semi-Rigid Fixation Using a Sliding Plate for Treating Fractures of the Mandibular Condylar Process

Occlusal displacement often occurs after surgery for condylar process fractures because it is difficult to reduce these fractures precisely. However, performing semi-rigid fixation using a sliding plate may overcome this limitation. A retrospective clinical comparison between semi-rigid and rigid fixations was performed. Among 34 patients who had unilateral condylar process fractures, 17 were treated with rigid fixation and the remaining with semi-rigid fixation using a sliding plate. For all patients, panoramic radiographs were collected 1 day and 6 months after surgery. In these radiographs, ramus height and condylar process inclination were measured, and the differences between the fractured and normal sides were assessed. Additionally, the radiographic density of the fracture area was measured. Differences in surgical outcomes and operative times between the two groups and changes in postoperative deviations within each group were analyzed. There was no statistically significant difference in ramus height and condylar process inclination between the two groups at postoperative day 1 and 6 months. Radio-density was observed to be higher in the rigid fixation group, and it increased with time in both groups. The semi-rigid fixation group had a significantly shorter operative time than the other group did. Semi-rigid and rigid fixations showed no differences in terms of effectiveness and outcomes of surgery. In terms of operative time, semi-rigid fixation was superior to rigid fixation.

Inter Maxillary Fixation Versus Open Reduction for the Treatment of Mandibular Condyle Fractures: A Comparative Evaluation

Background:

The treatment for fractured mandibular condyles aims at restoring the masticatory ability, occlusion, symmetry, and function as the bit were before the trauma. The treatment of the mandibular condylar fracture can be done based on the two protocols.

Aims:

The present clinical trial was conducted to collate aftertreatment upshot of closed treatment and open surgical treatment for mandibular condyle fractures.

Materials and Methods:

Forty-two patients were divided into two groups (n = 12) which were treated with either the closed reduction using intermaxillary fixation or open reduction and internal fixation. The following clinical parameters were assessed at 1^st and 3^rd day and at 1, 3, and 6 weeks: lateral excursion and protrusion, occlusion; interincisal opening, mandibular ramus height, deviation/deflection during jaw opening, and pain assessment using visual analog score. The collected data were subjected to statistical evaluation.

Results:

Interincisal opening was found to be 8.125 ± 0.3467 mm and 6.016 ± 0.1528 mm, respectively, for Group I and Group II which was statistically significant (P < 0.00001). At the 3 months and 6^th week postoperatively, it was increased in the surgical groups to 17.433 ± 0.3822 mm and 19.175 ± 0.3696 mm, respectively.

Conclusion:

The present trial suggests surgical open reduction and internal fixation treatment of the mandibular condylar fracture is better than the nonsurgical closed reduction in terms of interincisal opening, lateral excursion, and protrusive mandibular movement range.

Will Closed Treatment Provide Better Mandibular Motion Than Open Reduction and Internal Fixation in Cases of Unilateral Displaced Subcondylar Fracture? A Systematic Review and Meta-Analysis

PURPOSE

The aim of the present systematic review was to determine whether closed treatment (CLT) with intermaxillary fixation (IMF) is superior or equivalent to open reduction and internal fixation (ORIF) in the management of unilateral displaced subcondylar fractures regarding the range of mandibular motion.

MATERIALS AND METHODS

To address our question, we conducted a systematic review and meta-analysis of the reported data after a comprehensive manual and electronic database search of studies reported up to 2017 in the English language that had compared CLT and ORIF of mandibular condyle fractures in adults. The following outcomes were recorded: maximum interincisal opening (MIO), protrusive movement (PM), lateral excursion toward the fractured side (LEFS), and lateral excursion toward the nonfractured side (LENFS).

RESULTS

The search resulted in 8 studies, 4 of which were included in the meta-analysis. The MIO and PM showed no statistically significant differences, with an effect size of -0.823 (P = .112) and -0.633 (P = .079), respectively. However, the LEFS and LENFS were superior after CLT, with an effect size of -0.710 (P = .031) and -0.682 (P = .017), respectively.

CONCLUSIONS

The findings from the present review suggest that both ORIF and CLT can provide comparable MIO and PM in subjects with unilateral displaced subcondylar fractures. However, CLT was superior to ORIF for both LEFS and LENFS.

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.

Long-term Stability after Reduction of Mandible Fracture by Keyhole Plate: Evaluation at the Time of Plate Removal

Background

Various types of miniplates have been developed and used for the reduction of facial bone fractures. We introduced Yang’s Keyhole (YK) plate, and reported on its short-term stability. The purpose of this study was to evaluate the long-term stability of the YK plate, as a follow-up study, by examining the patients who had used the YK plate among the patients with the reduction of mandible fractures and who visited for plate removal.

Methods

We reviewed the medical records of 16 patients who underwent mandibular fracture fixation using a YK plate (group I) and 17 patients who underwent mandibular fracture fixation using a conventional plate (group II). Assessment was then made on malunion, occlusal stability, discomfort during the application, and clinical symptoms.

Results

From January 2015 to December 2017, a total of 36 patients underwent mandibular fracture surgery using a YK plate. A total of 16 patients received plate removal. Among them, 15 were male and 1 female. The average age was 26 years. The applied surgical sites were the 12 on mandibular angle, 4 on mandibular symphysis, and 2 on subcondyle. The application period of YK plate was an average of 335 days. During the same period, 45 people underwent surgery on the conventional plate. A total of 17 patients received plate removal. Among them, 15 were male and 2 females. The average age was 36 years. The applied surgical sites were the 8 on mandibular angle, 4 on mandibular symphysis, and 2 on subcondyle. The application period of the conventional plate was an average of 349 days. No malocclusion occurred at the time of removal, and occlusion was stable. No patient complained of joint disease or discomfort.

Conclusion

The YK plate system, in which the screw was first inserted and the plate was applied, for clinical convenience did not cause any particular problem and no significant difference from the conventional plate.

A comparative study of intraoral versus retromandibular approach in the management of subcondylar fracture

Background

The purpose of this study was to compare the outcomes and effectiveness between intraoral approach and retromandibular approach for treatment of subcondylar fracture of mandible.

Methods

Between March 2011 and October 2013, 24 patients with subcondylar fractures of the mandible were treated by a single surgeon with an intraoral approach using an angulated screwdriver (n = 14) or by another surgeon using a retromandibular approach (n = 10). The interincisal distance was measured 1 week (T0), 6 weeks (T1), 3 months (T2), and 6 months (T3) postoperatively. We also compare the average operation time and the cost of operation between the two groups.

Results

At 6 months postoperatively, all 24 patients achieved satisfactory ranges of temporomandibular joint movement, with an interincisal distance > 40 mm without deviation and with stable centric occlusion. The intraoral group had the median interincisal distance of 14 mm at T0, 38 mm at T1, 42.5 mm at T2, and 43 mm at T3, while the retromandibular group had that of 15, 29, 35, and 42.5 mm respectively. There was no statistically significant difference between the intraoral and the retromandibular group at T0 and T4. However, significant differences were noted T1 and T2 (p < 0.01). The differences of average operation time between the intraoral (81 min) and retromandibular group (45 min) were statistically significant (p < 0.01). The cost of an operation was 369.96 ± 8.14 (United States dollar [USD]) in intraoral group and was 345.48 ± 0.0 (USD) in retromandibular group. The differences between the two groups were statistically significant (p < 0.01).

Conclusion

In open reduction of a subcondylar fracture of the mandible, a intraoral approach using an angulated screwdriver is superior to the retromandibular approach in terms of interincisal distance, although the operation time is longer.

Use of Transgingival Lag Screw Osteosynthesis in the Management of Alveolar Process Fracture

The purpose of this study is to check the efficacy of transgingival lag screw osteosynthesis in alveolar process fractures of maxilla and mandible. A single-arm nonrandomized observational study was performed for the treatment of alveolar process fractures of maxilla and mandible. In this study, 20 mixed age group patients with alveolar process fracture were included. All the patients were treated by a 2.0-mm transgingival screw fixation under local or general anesthesia. All the patients were evaluated for fracture stability, anatomical reduction, bone loss and bone resorption of alveolar process, tooth loss, and wound infection at 3 months of follow-up. A simple descriptive statistical analysis was done to evaluate the parameters and it was shown that the treatment of alveolar process fracture with two or three lag screws provides adequate fracture stability and anatomical reduction with no signs of bone loss and tooth loss, and wound infections were noted post lag screw fixation. The study concludes that transgingival lag screw fixation is a suitable alternative for alveolar process fractures in all the age groups and two to three lag screws are generally sufficient to fix fractured alveolar process either under local anesthesia or general anesthesia.

Condylar Fractures: Surgical Versus Conservative Management

Background and Objectives

Condylar fractures can be treated with one of the two methods, including the conservative (closed reduction and immobilization) and/or surgical (open reduction and internal fixation) methods. Both these modalities of treatment have their indications and contraindications and merits and demerits. The present study was designed with the purpose of comparing the outcomes of surgical versus conservative management of moderately displaced subcondylar and condylar neck fractures.

Materials and Methods

The present study included a total of 20 patients with moderately displaced condylar fractures in patients > 18 years of age who were randomly divided into nonsurgical and surgical group and were managed accordingly. In the present study, the outcomes of conservative versus surgical management of subcondylar and condylar neck fractures were discussed in terms of seven parameters, including the maximal interincisal mouth opening, protrusive and lateral excursive movements of the mandible, status of occlusion, deviation of mandible during mouth opening, pain (in terms of visual analog scale) and the height of ascending ramus (radiographically) which were measured and evaluated pre- and post-operatively at different intervals of time. The follow-up was done for a period of up to 6 weeks postoperatively.

Statistical Analysis Used

Descriptive and analytical statistics were calculated using the Statistical Package for Social Sciences version 19. The Mann-Whitney U-test was used to assess the significance of the difference between the groups, whereas the Wilcoxon signed-rank test was used to assess the significance of the difference between the paired observations in each group.

Results

Patients treated surgically showed better improvement in maximal interincisal mouth opening, lateral excursions with minimal deviation, early relief from pain, and restoration of height of the ramus with symmetry in comparison with the patients managed conservatively where prolonged periods of pain apart from obvious deviation and minimal restoration of height of the ramus was observed over a follow-up period of 6 weeks postoperatively. The results were also found to be statistically significant with the value of P < 0.05.

Interpretation and Conclusion

Surgery is inarguably preferred over conservative management of moderately displaced condylar fractures as per the results of the present study. The present study provided valuable information and mandated further studies with larger sample sizes to come to definitive conclusions.

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

PURPOSE

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

METHODS

A systematic review and meta-analysis were performed that included several databases with specific keywords, a reference search, and a manual search for suitable articles. The inclusion criteria were all clinical trials, with the aim of assessing the rate of facial nerve injuries when open reduction and internal fixation (ORIF) of condylar process fractures was performed using different surgical approaches. The articles had to have documented the number of encountered facial nerve branches during ORIF. The main outcome variable was transient and permanent facial nerve injury. The dependent variable was the event and/or number of encountered facial nerve branches during surgery, and how they were handled (i.e. dissected, retracted, etc.).

RESULTS

A total of 1202 mandibular condylar fractures were enrolled in 29 studies. Rate of transient facial nerve injury (TFNI) was 11.3 % (136/1202). The number of facial nerve branches encountered intraoperatively was 543, namely buccal, marginal mandibular, zygomatic and temporal nerve branches. There was a significant correlation suggesting that there is a strong positive linear relationship between TFNI and encountered facial nerve branches (Coef = 0.1916, P = 0.001). There was no significant relationship between permanent facial nerve injury and encountered facial nerve branches (P = 0.808). TFNI was 4.3% and 18.7% for those studies expressly reporting that facial nerve branches were encountered incidentally without dissection and with dissection, respectively. For studies reporting deliberate and systematic facial nerve dissection, TFNI was 20.9%. Finally, studies that did not report any encounters of facial nerve branches, TFNI was 7.9 %.

CONCLUSION

This meta-analysis demonstrated that manipulation of the facial nerve during different surgical approaches causes different incidences of facial nerve injury. The choice of surgical approach for a given fracture should take this into consideration.

In Vitro Effect of 3D Plates Used for Surgical Treatment of Condylar Fractures on Prostaglandin E₂ (PGE₂) and Thromboxane B₂ (TXB₂) Concentration in THP-1 Macrophages

Recent studies have shown promising results concerning the effectiveness of 3D plates in terms of stabilization of condylar fractures. Despite the use of new techniques and new materials, we can still observe certain side effects, including the immune reaction of the body, which may lead to the excessive inflammation. The aim of this paper was to determine how the production of prostaglandin E₂ (PGE₂) and thromboxane B₂ (TXB₂) in THP-1 monocytes/macrophages is influenced by the titanium 3D plates and dedicated screws. The experiments were conducted on THP-1 monocytic cell line and macrophages derived from a THP-1cells. The concentrations of PGE₂ and TXB₂ released were measured by using immunoassay kit. Verification of plate-induced activation of THP-1 monocytes and macrophages and initiation of inflammatory reaction was conducted by flow cytometry. Despite some differences in the content of the implant devices our results showed that these plates did not statistically significantly increase the production of these prostanoids. Osteosynthesis of condylar fractures using 3D titanium mini-plates seems to be a good alternative to traditional plates due to their lack of stimulating the cyclooxygenase-dependent production of prostanoids; limiting the development of inflammatory reactions.

A New Method of Fixation With the Yang's Keyhole Plate System for the Treatment of Mandible Fractures

PURPOSE

This study was designed to assess the clinical outcomes and surgical convenience of a newly designed Yang's Keyhole plate (YK plate) system for treatment of subcondyle and angle fractures of the mandible. To evaluate the system's clinical outcomes and surgical convenience, chart review and surgical simulation using a mandible replica model were performed.

METHODS

The YK plate system, which is a slightly modified sliding plate, has 0.8-mm thick titanium and a widened hole in the anterior region to permit a screw head to be inserted. The clinical results and clinical convenience of the newly developed YK plate system and the existing 4-hole miniplate fixation technique were compared using a surgical simulation. Moreover, the clinical results of the patients who underwent mandibular surgery were compared during the follow-up examination periods (ie, weeks 1, 2, 4, 8, and 16).

RESULTS

No critical complications in any of the 22 patients were reported during the 4-month follow-up period. The results of the assessment of clinical convenience using the surgical simulation showed that using the YK plate system was more convenient and saved time compared to using the 4-hole miniplate.

CONCLUSION

The newly developed YK plate system can be applied to subcondyle and angle fractures of the mandible and can provide reliable and convenient application and use.

Prospective study of treatment outcomes with lag screw versus Herbert screw fixation in mandibular fractures

The principle of axial compression for better adaptation of fracture segments, with the advantage of increased stability and early function, is a promising means of avoiding the bulky rigid plates used previously. This study was done to compare the treatment outcomes between Herbert screw and lag screw fixation in mandibular fractures. Thirty patients with oblique displaced or undisplaced mandibular fractures requiring open reduction and internal fixation with rigid screw fixation, under general anaesthesia, were included. Herbert screws were used in 15 patients (group 1) and lag screws were used in the other 15 patients (group 2). Patients were followed up at 1 week, 6 weeks, 3 months, and 6 months for postoperative occlusion, inter-fragmentary mobility, pain, nerve sensation, and isodensity values on panoramic radiographs. Postoperative occlusion, inter-fragmentary mobility, pain, and nerve sensation were similar in the two groups. Group 1 patients attained isodensity values similar to the final follow-up value much faster than group 2 patients (P<0.05). This study strongly suggests that the use of Herbert screws results in significantly faster healing as compared to lag screws, in terms of achieving higher isodensity values faster.

Efficacy of Retromandibular Transparotid Approach for the Management of Extracapsular Subcondylar Mandibular Fractures Using 2-mm Titanium Miniplates: A Prospective Clinical Study

PURPOSE

The aim of this study was to evaluate the long-term clinical and radiologic results of the retromandibular transparotid approach to displaced extracapsular subcondylar mandibular fractures.

PATIENTS AND METHODS

A prospective cohort study was conducted over a period of 5 years on patients surgically treated for displaced extracapsular subcondylar mandibular fractures by the retromandibular transparotid approach. Variables including the type of fracture, degree of mouth opening, fracture displacement, deviation, excursive movements of the mandible, and facial nerve function were monitored before and after treatment. Appropriate statistics were computed.

RESULTS

Thirty-nine patients with 47 fractures were evaluated. There were 34 subcondylar fractures (located below the sigmoid notch) (87%), and 5 fractures were located in the head region in bilateral cases. Of the fractures, 31 (79%) were unilateral and 8 (21%) were bilateral. In a multivariate study, condylar coronal displacement, coronal sagittal displacement, difference in the ramal height, maximal interincisal distance, protrusive movements, and deviation of the mandible on opening showed statistically significant differences in pretreatment and post-treatment patients (P = .001). The interincisal distance was 46.8 mm (SD, 5.2 mm) postoperatively versus 24.1 mm (SD, 6.7 mm) before treatment. The average range of protrusion was significantly lower (P = .001) in patients before treatment, at 1.9 mm (SD, 1.2 mm), when compared with 6.1 mm (SD, 2.0 mm) postoperatively. During mouth opening, deviation of the mandible is often a sign of compensatory movement of the contralateral joint due to shortening of the ascending ramal height on the affected joint. The mean deviation of the mandible from the midline was 4.2 mm (SD, 1.0 mm) in patients before treatment, with a significant difference (P = .001) in patients after treatment, with a mean of 1.9 mm (SD, 0.995 mm). Temporary injuries to the facial nerve branches were observed in 3 cases (8%) 1 week after treatment, which later resolved within 3 weeks to 3 months.

CONCLUSIONS

The retromandibular transparotid approach provides good exposure and facilitates accurate reduction and fixation of the subcondylar fragment with positive outcomes, good cosmetic results, and rare major complications. Most facial nerve injuries are transient in nature after this approach. A Synthes 2-mm titanium single mini-plate (West Chester, PA) provides stable results after fixation.

Evaluation of Retro Mandibular Approach to Open Reduction and Internal Fixation of Condylar Fractures: A Cross-sectional Study

PURPOSE

The present study was carried out to evaluate the usefulness of mini retromandibular approach on accessibility, scarring and stability in open reduction and internal fixation of sub condylar fractures.

MATERIALS AND METHODS

Fifteen patients underwent open reduction and rigid fixation of middle and low subcondylar fractures, with mini-retro mandibular approach.

RESULTS

No signs of infection were observed in any patient postoperatively. Surgical scar was imperceptible and esthetically acceptable in all the cases. Out of 15 patients, only one patient had discrepancy in occlusion and after 2 months satisfactory centric occlusion was achieved. Salivary fistula (parotid fistula) was observed in 3 cases within 1 week postoperatively, which was treated spontaneously with the use of hypertonic saline. Transient facial nerve weakness was observed in 2 patients, in one patient it resolved in 4 weeks postoperatively and in second patient 3 months postoperatively. Mouth opening increased in all the patients with time. Average mouth opening at 1 week interval was 19.6 mm, at 2 months interval 28.2 mm, and after 6 months 38.33 mm suggesting that mouth opening gradually increased with time. At the end of 2 months postoperatively none of the patients had any restriction in lateral movements. At 2 months postoperatively 4 patients had deviation but none of the patients had any deviation 6 months postoperatively.

CONCLUSION

It is evident from the results of our study that open reduction and internal fixation using mini-retromandibular approach is good treatment option in management of mandibular condylar fractures.

Evaluation of mechanical resistance after fixation of mandibular condylar fracture with single and double miniplates: a comparative in vitro study

OBJECTIVES

To evaluate the efficacy of two plating system in comparison with single plating systemTo study the biomechanical behaviour of single and two plating system when compression load is applied.

MATERIALS AND METHODS

Twenty hemimandibles were divided into two groups A and B of ten each. A subcondylar fracture was created. Group A was stabilized by single adaptation plating technique and group B by double adaptation plating technique and both the groups were tested for stability by using universal testing machine.

RESULTS

Higher mean displacement was observed in Group A compared to Group B, but the difference in mean displacement between the two groups was not statistically significant (p > 0.05). Higher mean load was recorded in group B compared to group A and the difference in mean load between them was found to be statistically significant (p < 0.001).

CONCLUSION

The present study demonstrated that double adaptation plating technique had greater resistance to compression load than single adaptation plating technique and it shows more favorable biomechanical behavior.

Development and Clinical Evaluation of MatrixMANDIBLE Subcondylar Plates System (Synthes)

In this article, authors report the different steps of development and clinical validation of MatrixMANDIBLE Subcondylar Plates (Synthes, Soletta, Switzerland), a specialized osteosynthesis system developed by Synthes during the past 4 years. Between 2009 and 2013, a total of 62 patients were treated for subcondylar and condylar neck fractures via a preauricular or retromandibular/transparotid approach. The MatrixMANDIBLE Subcondylar Plates System consists of a Trapezoidal Plate, a three-dimensional (3D) 4-hole 1.0-mm plate for smaller fracture areas, the Lambda Plate, a 7-hole 1.0-mm linear plate which mimics the two miniplates technique, and the Strut Plate, a 3D 1.0-mm plate with great versatility of employment. All devices satisfy the principles of a functionally stable osteosynthesis as stated by Champy et al. None of the plates broke and no macroscopic condylar displacement was noted on radiological follow-up. Clinical and functional parameters assessed at 6 months postoperative (mandibular range of motion, pain, dental occlusion) were almost restored. MatrixMANDIBLE Subcondylar Plates System (Synthes) has proved to provide sufficient mechanical stiffness and anatomically accurate fracture reduction to avoid major postoperative drawbacks of subcondylar and condylar neck fractures.

Inflammatory Morbidity due to Compound Mandibular Body Fractures: Does It Have a Relationship with Treatment Outcome?

OBJECTIVE

The aim of this study was to evaluate the relationship between the degree of preoperative pain and trismus with the development of complications following the repair of isolated unilateral compound mandibular body fractures using a closed reduction technique.

SUBJECTS AND METHODS

This was a 7-year prospective study carried out at the Dental and Maxillofacial Surgery Clinic of the University of Calabar Teaching Hospital, Calabar, Nigeria. Of a total of 97 patients, 83 (85.6%) subjects (66 males, 17 females, ratio 5:1) were preoperatively evaluated for trismus and pain in a blinded manner by a single examiner, and complications were recorded postoperatively. The data obtained were statistically analyzed with EPI Info 2008 software.

RESULTS

Of the 83 patients treated, 13 (15.7%) developed complications. The fractures were most common in the age range of 21-40 years (n = 45, 54.2%). The age (p = 0.02) and gender (p = 0.01) distribution of the subjects was significant. The more severe the limitation of mouth opening (p = 0.03) and pain (p = 0.04) before treatment, the more complications developed, and these significantly affected treatment outcome. Impaired mastication and facial asymmetry (n = 17, 41.5%) were the most common complications.

CONCLUSION

This study showed that posttrauma pain and trismus due to unilateral mandibular body fractures may be associated with the development of complications. An adequately powered prospective study treating patients at 5 or 7 days is required in order to make the case for later intervention.

Complications of mandibular fracture: study of the treatment methods in calabar, Nigeria

OBJECTIVE

The plethora of techniques available for the treatment of mandibular fractures suggests that there is controversy regarding their definitive outcome. The purpose of this study was to clinically study the complications associated with the different treatment methods of mandibular fractures at the University of Calabar Teaching Hospital (UCTH), Nigeria.

METHODS

This was a three-year prospective study carried out at the Dental and Maxillofacial Clinic of the hospital. Patients who met the inclusion criteria had their data recorded in a proforma questionnaire.

RESULTS

Out of the 256 patients studied, 17.2% developed complications. Complications were commoner (70.5%) between ages 21 and 50 years. Thirty-five (79.5%) were males while nine (20.5%) were females with a male:female ratio of 4.9:1. Following treatment by closed reduction, conservative and open reduction, 16.6%, 17.2% and 20.7% had complications, respectively. Whereas occlusal derangement was the most common complication, numbness of the cheek and lower lip was recorded following all treatment methods.

CONCLUSION

Although the complications recorded in this patient population were managed during postoperative follow-up period, the methods of treatment available give good results, are cost-effective and patient compliance is good. This suggests that the older methods of treatment of mandibular fractures can still be used with reliability in contemporary dental practice.

Effect of surgical repair of the joint capsule in mandibular condyle fractures in adult rats

PURPOSE

The aim of the present study was to assess histologic changes in the temporomandibular joint (TMJ) of adult rats subjected to unilateral fracture of the mandibular condyle and soft tissue injury.

MATERIALS AND METHODS

The animals were divided into 2 groups: one had surgical treatment for soft tissue repair and the other had no soft tissue treatment. All histologic evaluations were performed according to the presence or absence of synovitis, vascularity, presence or absence of joint inflammation, and presence or absence of the articular disc. The contralateral TMJs also were evaluated.

RESULTS

The results showed few histologic changes in the synovial membrane and joint disc for the 2 groups and in the synovial membrane and disc of the contralateral side, where indirect trauma occurred in the unoperated joint.

CONCLUSION

This study showed that treating or not treating soft tissues does not change the treatment results of condyle fracture or interfere with TMJ pathosis.

Comparison of Surgical and Nonsurgical Treatment of Bilateral Condylar Fractures Based on Maximal Mouth Opening

This study presents a comparative analysis of the open surgical and nonsurgical treatment of patients with bilateral condylar fractures. Sixty-seven (67) patients were treated, and the completed data on 55 patients were reviewed to compare both therapeutic modalities, which consisted of nonsurgical and surgical treatment in 37 and 18 patients, respectively. In the nonsurgical group, 23 patients (23/37, 62%) had normal mouth opening. Functional success rate was 79% (15/19) and 44% (8/18) in young adult patients (-29yrs) and older patients (30+yrs), respectively, and there was a significant difference of outcome between the two groups. In nonsurgically treated young patients with disorders, bilateral dislocation and existence of concomitant mandibular fractures were commonly observed. In the open surgical group, seven (7/11, 64%) young adult and three (3/7, 43%) older patients gained normal mouth opening, and no significant difference was observed. Additionally, there was no difference between non-surgical and surgical treatment in any category. Patients undergoing rigid fixation benefited from restoring maximum mouth opening, although there was no significant difference between the rigid and non-rigid fixation groups. Based on these findings, nonrigid fixation should be avoided, and rigid fixation might improve outcome in young adult patients with severe fracture pattern, such as bilateral dislocation and concomitant mandibular fracture.

Evaluation of facial nerve following open reduction and internal fixation of subcondylar fracture through retromandibular transparotid approach

The objective of this study was to evaluate any damage to the facial nerve after a retromandibular transparotid approach for open reduction and internal fixation (ORIF) of a subcondylar fracture. We studied 38 patients with 44 subcondylar fractures (3 bilateral and 38 unilateral) treated by ORIF through a retromandibular transparotid approach. All patients were followed up for 6 months. Postoperative function of the facial nerve was evaluated within 24h of operation, and at 1, 3, and 12 weeks, and 6 months. Variables including type of fracture, degree of mouth opening, postoperative occlusion, lateral excursion of the mandible, and aesthetic outcome were also monitored. Nine of the 44 fractures resulted in transient facial nerve palsy (20%). Branches of the facial nerve that were involved were the buccal (n=7), marginal mandibular (n=2), and zygomatic (n=1). In the group with lateral displacement, 2/15 showed signs of weakness, whereas when the fracture was medially displaced or dislocated 7/23 showed signs of weakness. Of the 9 sites affected, 7 had resolved within 3 months, and the remaining 2 resolved within 6 months. The mean (range) time to recovery of function was 12 weeks (3-6 months). There was no case of permanent nerve palsy. The retromandibular transparotid approach to ORIF does not permanently damage the branches of the facial nerve. Temporary palsy, though common, resolves in 3-6 months. Postoperative occlusion, mouth opening, and lateral excursion of the mandible were within the reference ranges. We had no infections, or fractured plates, or hypertrophic or keloid scars.

Comparative biomechanical evaluation of mono-cortical osteosynthesis systems for condylar fractures using photoelastic stress analysis

Fractures of the condyle account for 20-30% of all mandibular fractures, and are therefore one of the most common facial injuries. Precise evaluation of the mechanical stresses that develop in a fractured mandible is essential, particularly for the testing of systems currently used for stabilisation of the condylar fragment. Photoelastic stress analysis can be used to visualise alterations in the strain that is induced in the mandible by a fracture, and in the osteosynthesis materials used to stabilise it. This method, used on currently used osteosynthesis materials, showed that stabilisation of a subcondylar fracture with a single miniplate does not provide enough stability, whereas the use of two miniplates - properly positioned - offers sufficient stability in all loading conditions. A microplate may be used as a tension-resisting plate with equally good results.

A comparative clinical evaluation of the outcome of patients treated for bilateral fracture of the mandibular condyles

AIM

To compare open reduction and internal fixation (ORIF) with closed treatment and maxillomandibular fixation (CRMMF) for management of bilateral subcondylar fractures of the mandible.

PATIENTS AND METHODS

This study involved a retrospective analysis of bilateral subcondylar fractures of the mandible treated at Government Dental College, Rohtak from 2007 to 2010. Data were collected by a review of pertinent inpatient and outpatient clinic records, and radiographic results. Patients were followed up weekly for 4 weeks and then at 2, 3 and 6 months after surgery. At these visits, careful attention was paid to clinical parameters included mouth opening, protrusion, laterotrusion, deviation on mouth opening and occlusion.

RESULTS

The patient sample ranged in age from 19 to 55 years, with an average age of 28.2 years. In total, 44 patients with 88 mandibular subcondylar fractures were included in the study. Out of these, 20 patients were managed by closed treatment and 24 by ORIF of the subcondylar fractures (19 unilateral and 5 bilateral). Regarding mouth opening/lateral excursion/protrusion, significant (p=0.00) differences were observed between both groups (open 37.6/11.5/5.9 mm versus closed 31.5/7.8/3.1mm). The visual analogue scoring revealed significant (p=0.00) difference with less pain in the operative treatment group (1.3 open versus 7.2 closed). Statistically significant difference was found between two groups for occlusion (p=0.00).

CONCLUSION

The current retrospective study shows that operative treatment was superior in all objective and subjective functional parameters. It is concluded that if either of the condyles is displaced ORIF is the most satisfactory method of treatment.

Extracorporeal Fixation of Displaced Mandibular Condylar Fracture : Viable Option

BACKGROUND

To present a series of eighteen cases of displaced mandibular condylar fracture managed by extra-corporeal fixation. To evaluate the post operative results in terms of occlusal stability, temporomandibular joint function and radiological findings.

METHODS

A series of 18 cases were treated with extra corporeal fixation with mini plate and screws for displaced mandibular condylar fracture. Ramus was exposed through sub mandibular approach. A wire was passed through the angle of mandible to pull the mandible inferiorly. The displaced condyle was retrieved. A suitable bone plate was fixed to the condylar segment and it was repositioned and stabilized with screw with the distal segment. In three cases vertical sub-sigmoid osteotomy was carried out to retrieve the condylar head. After assembling the osteotomised segment and condylar segment, it was repositioned and stabilised in predetermined position. Post operatively the patients were on inter maxillary fixation for a week followed by active physiotherapy.

RESULT

The follow up period was between 2-11 years. In nine cases occlusion and mandibular function was good. There was no resorption of the condylar head. One case had complete resorption of the condylar head. Other case had fracture of the bone plate.

CONCLUSION

Extracorporeal fixation is an effective method for management of displaced and dislocated condylar fracture.