Management of Fractures of the Condyle, Condylar Neck, and Coronoid Process

Interventions for the Management of Mandibular Coronoid Process Fractures: A Systematic Review

Background

The fracture of the coronoid process of mandible is one of the rarest fractures seen and the paucity of literature on the topic reflects the same. Despite the low incidence rate, the complications maybe grave which is why proper management is important. The treatment is controversial also because of the absence of standardized treatment protocol. This systematic review aims to compare the outcome of various treatment modalities available.

Methods

Registered under PROSPERO: CRD42020200700. Systematic research was conducted across databases like PubMed, Google Scholar, Pro Quest, Wiley Online. All clinical studies done till January 2021 which included participants above 14 years of age were included. Case reports, case series and studies not mentioning the treatment plan were excluded. The studies were shortlisted by the authors based on the eligibility criteria. Risk of bias was assessed using the MINORS tool and JBI checklist.

Results

A total of five studies were included. Four were retrospective studies and one was a retrospective case-controlled study. Two studies reported high, two moderate and one low risk of bias. Various treatment modalities were reported for the management of coronoid process fractures including conservative management, ORIF and coronoidectomy. Most authors preferred conservative management in asymptomatic cases and surgical management in symptomatic cases.

Discussion

No randomized control trials were found on the topic. Majority of the articles were case reports. Conservative management was preferred in minimally displaced fractures of coronoid process. However, in presence of displaced coronoid process fractures causing impediment of mandibular function surgical management is preferred.

Management of Bilateral Condylar Fractures in an Edentulous Patient with Atrophic Mandible Using CADCAM Technology

Purpose

The objective of this article is to report the case of an edentulous patient with a diagnosis of bilateral condylar fracture, who was treated using virtual planning.

Methods

CAD/CAM technology was used for the design and manufacture of a Gunning splint, which was employed for open reduction of the right fracture and closed management of the left side.

Results

The reduction of the right condylar fracture projected in the planning was achieved, as well as the return of the vertical dimension and the restoration of function, after 28 months of observation.

Conclusion

In the case of total edentulism, the lack of occlusal guidance and bone atrophy are important variables to consider; however, tools such as CAD/CAM technology can be used to take more predictable treatment decisions and facilitate the execution of the procedures.

Computer-Aided Autogenous Coronoid Process Graft Combined With Median and Unilateral Sagittal Split Osteotomy for Late Reconstruction of Condylar Fracture and Occlusion after Trauma

PURPOSE

This study proposes a high-precision surgical technique that combines both computer-aided design/computer-aided manufacturing (CAD/CAM) and the screw-track transfer technique for condylar and occlusal reconstruction.

MATERIALS AND METHODS

A 43-year-old male patient with facial asymmetry, limited mouth opening, and malocclusion underwent condylar and occlusal reconstruction surgery. An autogenous coronoid process graft was performed by combining CAD/CAM and the screw-track transfer technique.

RESULTS

The surgical plan was transformed successfully from preoperative virtual surgical planning to actual surgery; this was confirmed by merging the postoperative computed tomography images with the preoperative three-dimensional surgical design. The patient recovered well and had better occlusion and facial symmetry, as well as an increased degree of mouth opening post-surgery. No complications were observed.

CONCLUSIONS

CAD/CAM combined with the screw-track transfer technique is a precise and feasible method that can be applied to autogenous coronoid process grafts. This approach can be used to reconstruct the condylar process and achieve a good occlusal relationship.

Radiological investigation of acute mandibular injury

This article focuses on the different imaging modalities used to evaluate acute mandibular fractures and explores important concepts relating to their diagnosis, investigation, and treatment. Significant focus will be given to exploring general management principles, considerations regarding first-line imaging, and recent technological advancement. Computed tomography (CT) is the preferred method when attempting to identify acute mandibular fractures, particularly in trauma patients, and has very high specificity and sensitivity. Multidetector CT now represents the standard of care, enabling fast scan times, reduced artifact, accurate reconstructed views, and three-dimensional (3D) reconstructions. Cone-beam CT is a newer advanced imaging modality that is increasingly being used worldwide, particularly in the ambulatory and intraoperative setting. It produces high-resolution images with submillimeter isotropic voxels, 3D and multiplanar reconstruction, and low radiation dose, however is less widely available and more expensive. Ultrasound is a valuable method in identifying a fracture in unstable patients, but is limited in its ability to detect nondisplaced fractures. Magnetic resonance imaging is useful in determining the presence of soft-tissue injury. CT angiography is invaluable in the assessment of potential vascular injury in condylar fracture dislocations.

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.

Multidetector CT of Mandibular Fractures, Reductions, and Complications: A Clinically Relevant Primer for the Radiologist

After the nasal bones, the mandible is the second most common site of facial fractures, and mandibular fractures frequently require open reduction. In the trauma injury setting, multidetector computed tomography (CT) has become the cornerstone imaging modality for determining the most appropriate treatment management, fixation method, and surgical approach. Multidetector CT is also used to assess the adequacy of the reduction and evaluate potential complications in the postoperative period. For successful restoration of the mandible's form and function, as well as management of posttraumatic and postoperative complications, reconstructive surgeons are required to have a detailed understanding of mandibular biomechanics, occlusion, and anatomy. To provide added value in the diagnosis, treatment planning, and follow-up of mandibular fractures, radiologists should be aware of these concepts. Knowledge of the techniques commonly used to achieve occlusal and anatomic reduction and of the rationale behind the range of available treatment options for different injury patterns-from isolated and nondisplaced fractures to multisite and comminuted fractures-also is essential. This article focuses on the use of multidetector CT for pre- and postoperative evaluation of mandibular fractures and outlines fundamental concepts of diagnosis and management-beginning with an explanation of common fracture patterns and their biomechanical underpinnings, and followed by a review of the common postoperative appearances of these fractures after semirigid and rigid fixation procedures. Specific considerations regarding fractures in different regions of the tooth-bearing and non-tooth-bearing mandible and the unique issues pertaining to the edentulous atrophic mandible are reviewed, and key features that distinguish major from minor complications are described. (©)RSNA, 2016.

A Comparative Evaluation of Closed and Open Treatment in the Management of Unilateral Displaced Mandibular Subcondylar Fractures: A Prospective Randomized Study

The aim of the study is to evaluate closed and open treatment in the management of unilateral displaced mandibular subcondylar fractures. Twenty patients with unilateral subcondylar fractures of the mandible were evaluated with degree of displacement of more than 20 degrees and ramal height shortening of more than 10 mm. They were informed of the need for 6-month follow-up. Patients were thoroughly informed, explaining the possible advantages and disadvantages of the open and closed treatment options. Radiographic parameters included the level of fracture, deviation of fragment, and ramal height shortening. Correct anatomical reduction is achieved by open treatment as compared with closed treatment. Regarding pain, mouth opening, and lateral excursion movement, statistically significant difference was found in both groups ( p  < 0.01). In radiographic assessment of ramal height shortening and fracture displacement, statistically significant difference was found ( p  < 0.01). And no significant complication is found in both treatment groups. The results of this study favor the open treatment for the management of displaced subcondylar fractures. However, the treatment results are also acceptable for closed group.

Risk factor analysis and idiographic features of mandibular coronoid fractures: A retrospective case-control study

This study aimed to identify and distinguish various factors that may influence the occurrence of mandibular coronoid fractures. From January 2000 to December 2009, a total of 1131 patients with maxillofacial fractures were enrolled in this statistical study to evaluate the association between mandibular coronoid fractures and other risk factors. Among these patients, 869 had mandibular fractures, and 25 sustained a total of 25 coronoid fractures. More than half (13 of 25 patients, 52%) of the coronoid fractures in these patients were caused by motor vehicle accidents. Among these coronoid fractures, seven were associated with other mandibular fractures, and 23 (92.0%) were related to midfacial fractures. The most common site of midfacial fracture was the zygomatic arch (20 patients, 80%). Multivariate logistic regression analysis revealed that the most important influencing factor was the zygomatic arch fracture (odds ratio, 9.033; 95% confidence interval, 1.658, 49.218; p = 0.011). The majority of coronoid fracture fragments (19 of 25, 76%) were removed during operation. The most commonly used incision is hemicoronal or bicoronal approach (16 of 19, 84.2%).