Management of Subcondylar Fracture through Intraoral Approach with Rigid Internal Fixation

A "Window" to Protect the Facial Nerve: A Descriptive Cadaveric Study

Introduction

Success in skeletal surgery depends on adequate access and exposure of the underlying skeletal structures. The retromandibular approach exposes the ramus condyle region through the posterior border of the mandible by utilizing the space between marginal mandibular and buccal branches of the facial nerve. Length of this safety window and accessibility varies in each individual owing to the differing ramifications of peripheral branches of facial nerve. These variations cannot be adequately assessed through clinical studies. Cadaveric studies permit us to extensively explore the surgical area to demystify the branching pattern and its relationship to the adjacent structures.

Method

Thirty well-preserved cadaveric facial halves were dissected using a retromandibular incision. Visibility and accessibility were objectively graded through a scale. The safety window and furcation distance were measured using caliper and scale. The appearance of the retromandibular vein was also noted.

Results

Eighteen facial halves showed maximum accessibility wherein the surgeon is expected to visualize the condylar neck, subcondylar region and posterior half of ramus. In 8 facial halves, accessibility was limited to subcondylar and midportion of posterior ramus, and in 8 facial halves, accessibility was limited to the midportion of ramus of the mandible. Safety window ranged from 1.9 to 3.5 cms. Distance between the posterior border of mandible and bifurcation of the facial nerve ranged from 0.5 to 1.5 cms. Facial nerve was encountered in 24 facial halves during the retromandibular approach. Retromandibular vein was encountered in 23 facial halves during the retromandibular approach.

Discussion

The retromandibular approach is a versatile approach to the condyle subcondylar area as it provides much-required visibility and accessibility. The facial nerve branching pattern and intercommunicating branches determine the safety window which is adequate in most cases. The retromandibular vein is a reliable landmark predicting the vicinity of the facial nerve.

Current Management of Subcondylar Fractures: A Systematic Review

OBJECTIVE

The aim of this study is to review the current literature on treatment of subcondylar fractures using traditional open reduction internal fixation (ORIF), closed reduction with maxillomandibular fixation (MMF), and endoscopic open approaches.

DATA SOURCES

PubMed, Embase, Cochrane CENTRAL, Clinicaltrials.gov, and WHO ICTRP.

REVIEW METHODS

A comprehensive database search was performed in accordance with PRISMA guidelines. All English-only texts published in the last 20 years with ≥10 patients were included. Studies that included patients <16 years old were excluded.

RESULTS

Thirty-two studies met the final inclusion criteria. Nine studies compared ORIF with closed reduction using MMF, 12 studies evaluated ORIF via different approaches, and 10 studies evaluated outcomes after endoscopic approaches. Five studies reported significant improvement in mouth opening with ORIF compared to closed reduction. In 1 study that recorded patient-reported outcomes measure (FACE-Q scale), quality of life scores and patient satisfaction were significantly higher in the ORIF group. Among the 10 studies that used the endoscopic approach, transient facial nerve injury ranged from 0% to 10%.

CONCLUSION

Several studies report better mouth opening, dental occlusion, and functional outcomes after ORIF compared to closed reduction, while some found no significant difference. Endoscopic approaches provide ease of access to the condyle with a low incidence of facial nerve injury. However, limitations include special equipment, longer operative times, and a steep learning curve using an endoscope. This review provides surgeons with an overview of the current literature on subcondylar fractures to allow for an individualized management approach for each patient.

A New Method for Surgical Treatment of Subcondylar Fractures: A Case Report

Subcondylar fractures are common in the maxillofacial region following direct trauma to the mandibular ramus. The literature is replete with articles written on the treatment of subcondylar fractures, encompassing a plethora of various surgical approaches; however, the best treatment procedure has remained controversial. Such fractures are either treated by open reduction with internal fixation or closed reduction with maxillomandibular fixation. In this article, we describe a new surgical method for treatment of subcondylar fractures.

Giant life-threatening external carotid artery pseudoaneurysm caused by a mandibular condylar fracture

OBJECTIVE

Vascular lesions are rare complications associated to mandibular condylar fractures. This paper aims to describe a case of a giant pseudoaneurysm involving the external carotid artery (ECA) caused by a condylar fracture.

CASE REPORT

A 33-year-old man was the victim of traffic accident and presented with a panfacial fracture, including a bilateral condylar fracture. The condylar fracture was treated by closed reduction, and 4 weeks after treatment, the patient developed facial edema, which suggested postoperative infection. An attempt at draining it resulted in intensive bleeding. A computed tomographic angiography showed a huge pseudoaneurysm originating from the ECA. The patient was treated with surgery with ligation of the ECA and drainage of the pseudoaneurysm.

CONCLUSION

Vascular complications associated with condylar fractures are rare, but surgeons should be aware of this type of complication, especially because of the high risk of serious damage, including death. The use of computed tomographic angiography is very helpful in the diagnosis of vascular lesions and also guides treatment.