A retrospective study of temporomandibular joint ankylosis secondary to surgical treatment of mandibular condylar fractures

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.

Complications of Mandibular Fracture Repair

Mandible fracture management has evolved dramatically. Therefore, the variety of surgical complications associated with mandibular fractures, and their incidences, have continued to change as well. This article aims to assess the most common and most concerning complications that can occur secondary to management of mandibular fractures by examining categories of complication types. This article also explores factors and techniques associated with reduced rates of complications as well as the management of complications.

Patient-specific plates for facial fracture surgery: A retrospective case series

OBJECTIVES

Surgeons often encounter challenges when treating maxillofacial fractures using conventional methods that involve trimming or bending ready-made titanium plates for open reduction and internal fixation (ORIF) since it can be time-consuming, imprecise, and inconvenient. This retrospective case series aimed to introduce a novel bone reduction method that utilizes virtual planning, patient-specific surgical guides, and titanium plates.

METHODS

Seven patients with mandibular symphysis or subcondylar fractures resulting from facial trauma underwent cone-beam computed tomography (CBCT) or facial CT scans, and their medical histories were documented. Virtual surgery was conducted based on three-dimensional (3D) stereolithography images derived from CT scans using the FaceGide software (MegaGen, Daegu, Korea). ORIF was performed using patient-specific surgical guides and plates that were designed, printed, and milled. Radiographic, clinical, and occlusal evaluations were conducted at two weeks and six weeks postoperatively. Subsequently, 3D images from virtual surgery and postoperative CT scans were compared.

RESULTS

The comparison of 3D virtual surgery and postoperative images revealed minimal surface differences of less than 1 mm. T-scan evaluations indicated that there were no statistically significant differences between the two- and six-week postoperative assessments. Favorable clinical outcomes were observed.

CONCLUSION

This novel method demonstrated stable outcomes in terms of occlusion and healing, with no notable complications. Consequently, this approach may serve as a viable alternative to conventional methods.

CLINICAL SIGNIFICANCE

Facial fracture surgery that utilizes patient-specific surgical guides and plates within a digital workflow can facilitate meticulous surgical planning, reducing the risk of complications and minimizing operation time.

Conservative management and follow-up of bilateral condylar fractures in pediatric patients: A case report

Key Clinical Message

Conservative treatment of bilateral condylar fractures, including intermaxillary fixation using arch bars and elastic bands, yields satisfactory results in pediatric patients. Therefore, the conservative approach should be considered the first line of treatment for bilateral condylar mandibular fractures in pediatric patients.

Abstract

Road traffic accidents (RTAs) are considered the leading cause of mortality and morbidity of children and adults in Saudi Arabia. Head injuries and fractures are the most common form of injuries resulting from RTAs, with mandibular fractures being the most common head injury; condylar fractures are the most frequent type of mandibular fracture. A review of the literature reveals diverse opinions about the best approach for treating bilateral condylar fractures in pediatric patients. The findings of the literature review are reported in this study. The case presented here shows the result of adopting a conservative approach to treating a bilateral extracapsular displaced condylar fracture. An elastic band was fixed onto intermaxillary fixation (IMF) screws at the midline upper and lower jaws; the patient was followed up for almost 3 years. The conservative approach yielded excellent results, as both condyles were fully repositioned and healed, without causing any deviation or limitation of the mouth opening. The results of this case support considering the conservative approach as the first line of treatment for bilateral condylar mandibular fractures in pediatric patients.

Two-screw osteosynthesis of the mandibular condylar head with different screw materials: a finite element analysis

This study compared the biomechanical behavior of titanium, magnesium, and polylactic acid screws for two-screw osteosynthesis of mandibular condylar head fractures using finite element analysis. Von Mises stress distribution, fracture displacement, and fragment deformation were evaluated. Titanium screws performed the best in terms of carrying the highest load, resulting in the least fracture displacement and fragment deformation. Magnesium screws showed intermediate results, while PLA screws were found to be unsuitable with stress values exceeding their tensile strength. These findings suggest that magnesium alloys could be considered a suitable alternative to titanium screws in mandibular condylar head osteosynthesis.

Serious Condylar Head Absorption in Children With Intracapsular Condylar Fractures Treated Operatively With Long Screws

OBJECTIVE

This study was performed to explore bone remodelling in children with intracapsular condylar fractures after the condylar fracture fragments were fixed using long screws and to offer possible explanations about the underlying mechanism.

PATIENT AND METHODS

Records of children (less than 12 y old) who sustained intracapsular condylar fractures and fixed with long screws from May 2012 to January 2015 were retrieved. Age, gender, dates of injury, admission, and discharge, mechanism of trauma, location and pattern of fracture, other mandibular fractures, treatment methods, and time of review were recorded and analyzed. Image dates of pretreatments and posttreatments, including the date of review, were also recorded.

RESULTS

A total of 8 patients completed their follow-up, and all patients (n=5) who were followed up after more than 3 months showed serious resorption of the condylar head. The condylar head resorbed until the height (or articular surface) dropped and aligned with the surface of the screw. The shortest time of absorption, as shown by the computed tomography scan was 106 days, and the longest time was 171 days (average time of 141.8 d).

CONCLUSIONS

Intracapsular condyle fractures in children should be managed conservatively as much as possible. However, if the height of the fracture fragments drops remarkably, open reduction and rigid internal fixation become possible choices.

Postoperative Computed Tomography for Facial Fractures

In order for a radiologist to create reports that are meaningful to facial reconstructive surgeons, an understanding of the principles that guide surgical management and the hardware employed is imperative. This article is intended to promote efficient and salient reporting by illustrating surgical approaches and rationale. Hardware selection can be inferred and a defined set of potential complications anticipated when assessing the adequacy of surgical reconstruction on postoperative computed tomography for midface, internal orbital, and mandible fractures.

Open Reduction Internal Fixation of Condylar Head/Diacapitular Fracture of Mandible: Case Series

Objective

Surgical management of condylar head is largely deferred due to the lack of appropriate armamentarium or instrumentation, restricted surgical access and risk of iatrogenic complications. Here we delineate open reduction internal fixation of condylar head fracture with various fixation modalities using specialized instrumentation for visualization and providing access for reduction with minimal complications.

Methods

A total of 21 patients were reported with condylar head fracture of mandible to the Department of Oral and Maxillofacial Surgery from January 2017 to June 2018. Three patients had bilateral condylar head fracture, making it a total of 24 fractures. All patients had clinical symptoms including deranged occlusion, limited mouth opening, jaw deviation and restricted mandibular movements. The radiological findings were dislocated or displaced condylar head medially or laterally. All patients were treated by open reduction internal fixation using lag screws or standard long screws.

Results

Among condylar head fractures, 19 of the study population were male and 2 were female. Distribution of age among the condylar head fractures ranges from 19 years to 40 years with the mean being 22 years. At the end of three-month follow-up, all patients had satisfactory results, both clinically and radiologically. The functional outcome of this study was found to be superior.

Conclusion

We recommend open reduction internal fixation of condylar head for patients with high risk of ankylosis, and it is possible without complications due to the availability of minimally invasive surgical access system.

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.

Is There a Role for Absorbable Metals in Surgery? A Systematic Review and Meta-Analysis of Mg/Mg Alloy Based Implants

Magnesium (Mg) alloys have received attention in the literature as potential biomaterials for use as absorbable implants in oral and maxillofacial and orthopedic surgery applications. This study aimed to evaluate the available clinical studies related to patients who underwent bone fixation (patients), and received conventional fixation (intervention), in comparison to absorbable metals (comparison), in terms of follow-up and complications (outcomes). A systematic review and meta-analysis were performed in accordance with the PRISMA statement and PROSPERO (CRD42020188654), PICO question, ROBINS-I, and ROB scales. The relative risk (RR) of complications and failures were calculated considering a confidence interval (CI) of 95%. Eight studies (three randomized clinical trial (RCT), one retrospective studies, two case-control studies, and two prospective studies) involving 468 patients, including 230 Mg screws and 213 Titanium (Ti) screws, were analyzed. The meta-analysis did not show any significant differences when comparing the use of Mg and Ti screws for complications (p = 0.868). The estimated complication rate was 13.3% (95% CI: 8.3% to 20.6%) for the comparison group who received an absorbable Mg screw. The use of absorbable metals is feasible for clinical applications in bone surgery with equivalent outcomes to standard metal fixation devices.

Management of Nonunion and Malunion After Primary Mandibular Condylar Fracture Treatment: A Review and Recommendations

PURPOSE

After primary treatment of mandibular condylar fractures, nonunion and malunion can result in considerable malocclusion and temporomandibular joint dysfunction owing to the integral role the condylar head plays in the temporomandibular joint. At present, the choice and timing of treatment are highly heterogeneous. The purpose of this study was to evaluate the current literature to identify possible pitfalls, discuss available treatment options, and make recommendations.

METHODS

The electronic databases PubMed, MEDLINE, PROSPERO, CENTRAL (Cochrane Central Register of Controlled Trials), and Embase were searched for content matching mandibular condylar fracture "revision surgery," "secondary surgery," "refracture," "malunion," and "malunion osteotomy." Articles in English, limited to human adults, published in the past 10 years, with abstracts and full text available and appropriate study designs, were included.

RESULTS

A total of 101 articles were retrieved for analysis, and 4 articles were included. Because of heterogeneity in these studies, a pooled analysis could not be performed.

CONCLUSIONS

Surgery can be considered as primary treatment of condylar fractures, and early detection of complications allows for early intervention, leading to better outcomes. Treatment of temporomandibular joint dysfunction is highly heterogeneous and ranges from nonsurgical measures to joint reconstruction. Unilateral malocclusion can often be corrected with unilateral surgery, but bilateral surgery may be indicated in select cases. Bilateral deformities often require bilateral mandibular surgery, but in cases with preserved symmetry, maxillary surgery can be performed.

Osteosynthesis of the Mandibular Condyle With Magnesium-Based Biodegradable Headless Compression Screws Show Good Clinical Results During a 1-Year Follow-Up Period

PURPOSE

The use of titanium-based implants in mandibular condyle fractures can require implant removal because of screw penetration through the condylar surface. The use of biodegradable implants can avoid a second operation for implant removal and the associated possible complications. We investigated the clinical and radiologic outcomes of osteosynthesis of mandibular condyle fractures (MCFs) with biodegradable magnesium-based compression screws.

MATERIALS AND METHODS

We performed a retrospective observational study of 6 patients who had been treated at our department. We recorded the changes in jaw movements over time, occlusion, and possible complications at defined intervals of 1, 3, 6, and 12 months postoperatively. We also compared the preoperative computed tomography (CT) scans with the postoperative cone-beam CT (CBCT) scans at 6 and 12 months postoperatively to evaluate mandibular condyle healing and screw degradation.

RESULTS

Of the 6 patients, 4 were men and 2 were women, with a mean age of 43.2 years (range, 30 to 66 years). All 6 patients had unilateral MCFs. All the patients showed well-restored function of the temporomandibular joint with significant improvement in mouth opening (46.17 ± 6.49 mm), right (10.67 ± 1.03 mm) and left (10.67 ± 1.97 mm) laterotrusion, and protrusion (10.17 ± 1.33 mm) distances to physiologic values. The CBCT scans showed the remodeling processes of the mandibular condyle and a few radiolucencies indicating the magnesium-based screws. Although penetration of 1 screw tip through the condylar surface had occurred, no implant removal was necessary owing to biodegradation of the implant.

CONCLUSIONS

The results of the present study have shown that biodegradable magnesium-based compression screws provide good clinical results and avoid implant removal.

Reducing macrophage numbers alleviates temporomandibular joint ankylosis

Temporomandibular joint (TMJ) ankylosis is a severe joint disease mainly caused by trauma that leads to a series of oral and maxillofacial function disorders and psychological problems. Our series of studies indicate that TMJ ankylosis development is similar to fracture healing and that severe trauma results in bony ankylosis instead of fibrous ankylosis. Macrophages are early infiltrating inflammatory cells in fracture and play a critical role in initiating fracture repair. We hypothesize that the large numbers of macrophages in the early phase of TMJ ankylosis trigger ankylosed bone mass formation and that the depletion of these macrophages in the early phase could inhibit the development of TMJ ankylosis. By analysing human TMJ ankylosis specimens, we found large numbers of infiltrated macrophages in the less-than-1-year ankylosis samples. A rabbit model of TMJ bony ankylosis was established and large numbers of infiltrated macrophages were found at 4 days post-operation. Local clodronate liposome (CLD-lip) injection, which depleted macrophages, alleviated the severity of ankylosis compared with local phosphate-buffered saline (PBS)-loaded liposome (PBS-lip) injection (macrophage number, PBS-lips vs. CLD-lips: 626.03 ± 164.53 vs. 341.4 ± 108.88 n/mm²; ankylosis calcification score, PBS-lips vs. CLD-lips: 2.11 ± 0.78 vs. 0.78 ± 0.66). Histological results showed that the cartilage area was reduced in the CLD-lip-treated side (PBS-lips vs. CLD-lips: 6.82 ± 4.42% vs. 2.71 ± 2.78%) and that the Wnt signalling regulating cartilage formation was disrupted (Wnt5a expression decreased 60% and Wnt4 expression decreased 73%). Thus, our study showed that large numbers of macrophages infiltrated during the early phase of ankylosis and that reducing macrophage numbers alleviated ankylosis development by reducing cartilage formation.

Prevalence of TMJ Disorders among the Patients Attending the Dental Clinic of Ajman University of Science and Technology-Fujairah Campus, UAE

The objective of this study was to determine the prevalence of temporomandibular joint (TMJ) disorders (if any) among the patients attending the dental clinic (for routine dental treatment) of Ajman University of Science and Technology (AUST)-Fujairah campus, UAE, and its possible causes. A sample of 100 adult patients attending the dental clinic of AUST for different types of dental treatment were collected; the routine examination of the TMJ and possible disorders such as clicking, crepitation, limitation or deviation during mouth opening, or tenderness reveals that 41% of the sample experience varying degrees of disorders in the TMJ. Radiographs were taken if needed (panoramic radiograph). The information was collected and recorded for each patient through questionnaires.

Relationship Between Intracapsular Fracture Patterns and Arthroscopic Findings

PURPOSE

To observe the superior joint compartment (SJC) using ultrathin arthroscopy in intracapsular condylar fracture (ICF) of the temporomandibular joint, describe the changes, and evaluate the relations among fracture pattern, arthroscopic findings, and clinical outcome.

PATIENTS AND METHODS

Twenty patients with 27 ICFs were the subject group. Thirteen patients had unilateral ICFs and 7 had bilateral ICF. The fracture patterns were classified into 9 categories, and all patients had arthroscopic examination of the traumatized joint at the time of definitive treatment. At 4 months after treatment of the injury, all patients had a secondary arthroscopy of the ICF joint. In all patients, range of motion (ROM) was measured as the interincisal distance (millimeters) at the first visit to 12 months after the first treatment, and the data were statistically evaluated.

RESULTS

Intra-articular hyperemia, hypervascularity, and temporal bone damage were found, and 4 patients had disc perforations at the first examination. At the second arthroscopy 4 months later, normal healing occurred in 11 joints, all of which had minimally displaced fractures. Fifteen joints showed complete filling of the SJC, all of which had a displaced minor fragment from the fossa. Comparison of the effect of the presence versus absence of SJC fibrosis on ROM showed marked differences from 1 to 12 months. The effect of early versus delayed definitive treatment showed marked differences at 4 and 12 months.

CONCLUSION

The intra-articular condition at 4 months after ICF as observed arthroscopically was related to the minor fragment position. If the minor fragment is nondisplaced, then it will heal to a normal state; however, if the minor fragment is displaced from the fossa, then the SJC shows disc damage and fibrosis. This could lead to fibrous ankylosis.

A review of temporomandibular joint-related papers published between 2014-2015

We conducted a retrospective study and reviewed the temporomandibular joint (TMJ)-related papers published in a leading international journal, Journal of Oral and Maxillofacial Surgery, between January 2014 and December 2015. The study was conducted to ascertain and compare the trends of articles being published in the years 2014 and 2015. A total of 28 articles were reviewed, of which most of the full-length articles were on clinical management and outcomes and the role of radiology. The bulk of the studies were prospective, and less interest was shown in experimental research. A thorough review and analysis thus gives the impression that there is a great need for well-designed clinical studies on TMJ.

Stereolithographic model-assisted reconstruction of the mandibular condyle with a vascularized fibular flap following hemimandibulectomy: Evaluation of morphological and functional outcomes

The vascularized fibular flap is one of the standard treatment choices for the reconstruction of the mandible; however, the consequences of condylar restoration have not previously been reported. The use of three-dimensional models allows for a more predictable reconstruction. The purpose of the present study was to assess the outcome of stereolithographic model-assisted reconstruction of the mandibular condyle with a vascularized fibular flap. A total of 5 patients underwent mandibular resection including the condyle and immediate reconstruction with a vascularized fibular flap. A stereolithographic model was used to determine the length and angle of the bony reconstruction. In all patients, the temporomandibular joint (TMJ) disc was preserved, and the contoured fibular end was placed directly into the glenoid fossa under the TMJ disc. To investigate the morphological and functional outcomes, radiographic and clinical examinations were performed, and a food scale questionnaire was administered. The mean period of follow-up was 23 months, and all the flaps were viable. Cosmetic results were generally satisfactory. Radiographic assessment revealed that the end of the fibular graft became round-shaped. None of the patients had abnormal bone resorption, dislocation or ankylosis. The mean value of maximum mouth opening was 31 mm. No patients exhibited difficulties with occlusion. All patients recovered their ability to ingest nearly the same foods that were ingested prior to surgery. The stereolithographic model-assisted reconstruction of mandibular condyle with a vascularized fibular flap is therefore useful for morphological and functional reconstructions of the hemimandible, including condylar defects.

Intraoperative arthroscopy of the TMJ during surgical management of condylar head fractures: A preliminary report

PURPOSE

The purpose of this preliminary study was to evaluate intraarticular soft tissues of the temporomandibular joint (TMJ) using intraoperative arthroscopy during open reduction and internal fixation (ORIF) of condylar head fractures (CHF).

MATERIALS AND METHODS

26 patients (29 joints) were diagnosed in period of 5 years (2011-2015) with CHF, 5 patients had concomitant mandibular fracture. Fractures were diagnosed on basis of conventional orthopantomogram (OPG) and computed tomography (CT).

RESULTS

Intraoperative arthroscopy revealed hyperemia and hypervascularity in all 29 joints, anterior disc dislocation in 26 joints, cartilage erosion in 21 joints and hemorrhagic clots were present in 10 joints. Major hemarthrosis or tear of the posterior band, as often described in MRI, could not be shown in our patients. Data from the study further the understanding of intraarticular pathology of the TMJ after acute trauma in a group with CHF.

CONCLUSION

Intraoperative arthroscopy is useful for direct evaluation and accurate diagnosis of the extent of soft tissue damage to TMJ in CHF. Larger and more long-term studies including comparison to MRI findings should be helpful to refine the treatment and postoperative management of patients after CHF.

Temporomandibular joint ankylosis caused by condylar fractures: a retrospective analysis of cases at an urban teaching hospital in Nigeria

Mandibular condylar fractures are common presentations to hospitals across the globe and remain the most important cause of temporomandibular joint (TMJ) ankylosis. This study aimed to analyze cases of mandibular condylar fracture complicated by TMJ ankylosis after treatment. A 16-year retrospective analysis was performed at the dental and maxillofacial surgery clinic of the study institution; patient data were collected from the hospital records and entered into a pro-forma questionnaire. It was found that 56/3596 (1.6%) fractures resulted in TMJ ankylosis. The age of patients with ankylosis ranged from 12 to 47 years. The age (P=0.03) and gender (P=0.01) distributions were significant, with most cases of ankylosis occurring in those aged 11-30 years (n=43/56, 76.8%). Fractures complicated by ankylosis were intracapsular (n=22/56, 39.3%) and extracapsular (n=34/56, 60.7%). Ankylosis increased significantly with the increase in time lag between injury and fracture treatment (P=0.001). Ankylosis was associated with concomitant mandibular (85.7%) and middle third (66.1%) fractures. Treatment methods were not significantly related to ankylosis (P=0.32). All cases of ankylosis were unilateral, and complete (n=36, 64.3%) and incomplete ankylosis (n=20, 35.7%) were diagnosed clinically. The incorporation of computed tomography scans and rigid internal fixation in the management of condylar fractures will reduce ankylosis.