The Role of Intra-articular Surgery in the Management of Mandibular Condylar Head Fractures

Does surgical treatment of mandibular condyle head (diacapitular) fractures provide better outcomes than closed treatment? - a systematic review and meta-analysis

The choices for managing a condylar head fracture (CHF) of the mandible are either open surgical or closed functional treatments (CFT) and the decision depends on various factors. The purpose of this systematic review was to ascertain from the available literature whether the open method or CFT yields better outcomes in managing CHF. We have systematically reviewed published articles according to the PRISMA statement. The search was conducted in PubMed, Google Scholar, Semantic Scholar, and the Cochrane Library database for comparative studies about both open and closed treatments from inception until April 2023. The outcomes of interest were mouth opening (MO), protrusion, laterotrusion, postoperative pain, and malocclusion. Eight studies met the inclusion criteria. The review comprised of 326 cases, among which 177 were managed by open methods and 149 were treated by CFT. The incidence of postoperative malocclusion and pain were significantly less in the open group. MO was better in the open treatment group although this was not statistically significant. Protrusion and laterotrusion occurred slightly more in CFT, although these were also statistically not significant. Overall, meta-analysis favoured open methods of managing CHF. Although enough evidence exists for the use of open methods for selected condylar head fractures, CFT still demonstrated favourable outcomes in undisplaced fractures. The selection of a particular treatment method should be individualised on the basis of each particular case considering the risk/benefits. Further high quality randomised trials are needed to establish a therapeutic guideline.

The current regenerative medicine approaches of craniofacial diseases: A narrative review

Craniofacial deformities (CFDs) develop following oncological resection, trauma, or congenital disorders. Trauma is one of the top five causes of death globally, with rates varying from country to country. They result in a non-healing composite tissue wound as they degenerate in soft or hard tissues. Approximately one-third of oral diseases are caused by gum disease. Due to the complexity of anatomical structures in the region and the variety of tissue-specific requirements, CFD treatments present many challenges. Many treatment methods for CFDs are available today, such as drugs, regenerative medicine (RM), surgery, and tissue engineering. Functional restoration of a tissue or an organ after trauma or other chronic diseases is the focus of this emerging field of science. The materials and methodologies used in craniofacial reconstruction have significantly improved in the last few years. A facial fracture requires bone preservation as much as possible, so tiny fragments are removed initially. It is possible to replace bone marrow stem cells with oral stem cells for CFDs due to their excellent potential for bone formation. This review article discusses regenerative approaches for different types of craniofacial diseases.

Open Treatment with Ultrasound Activated Resorbable Pins Versus Closed Treatment of Adult Mandible Condylar Head Fractures

Purpose

The purpose of the study was to investigate whether open reduction and internal fixation (ORIF) with ultrasound activated resorbable pins (UARPs) is superior to closed treatment of condylar head (CH) fractures. The investigators hypothesized that fixation with UARPs is superior to closed treatment of CH fracture.

Methods

It was a prospective pilot study on CH fracture patients. Patients in closed group were managed conservatively with arch bar fixation and elastic guidance. Fixation in open group was done with UARPs. Assessment was done for primary objective of stability of fixation by UARPs and secondary objectives of functional outcome and complications.

Results

The study sample included 20 patients (10 in each group). 10 patients (11 joints) in closed group and 9 patients (10 joints) in open group were available for final follow-up. 5 joints showed re-dislocation of fractured segment, 1 joint showed slightly imperfect but adequate fixation and 4 joints showed adequate fixation in open group. In the closed group, displaced fragment was fused with mandible at displaced position in all the joints. All the joints showed resorption of medial condylar head at 3 months follow-up in open group. There was minimal resorption of condyle in closed group. Occlusion was deranged in 3 patients in open group and 1 patient in closed group. MIO, pain scores and lateral excursions were equal in both the groups.

Conclusion

The results of the present study rejected the hypothesis that fixation of CH with UARPs was superior than closed treatment. There was resorption of medial CH fragment in open group as compared to closed group.

Virtual surgical planning is a useful tool in the surgical management of mandibular condylar fractures

PURPOSE

The aim of this study is to evaluate the application value of virtual surgical planning in the management of mandibular condylar fractures and to provide a reliable reference.

METHODS

This was a prospective randomized controlled study and recruited 50 patients requiring surgical treatment for their mandibular condylar fractures. The inclusion criteria were patients (1) diagnosed with a condylar fracture by two clinically experienced doctors and required surgical treatment; (2) have given consent for the surgical treatment; and (3) had no contraindications to the surgery. Patients were excluded from this study if: (1) they were diagnosed with a non-dislocated or only slightly dislocated condylar fracture; (2) the comminuted condylar fracture was too severe to be treated with internal reduction and fixation; or (3) patients could not complete follow-up for 3 months. There were 33 male and 17 female patients with 33 unilateral condylar fractures and 17 bilateral condylar fractures included. The 50 patients were randomly (random number) divided into control group (25 patients with 35 sides of condylar fractures) and experimental group (25 patients with 32 sides of condylar fractures). Virtual surgical planning was used in the experimental group, but only clinical experience was used in the control group. The patients were followed up for 1, 3, 6 and 12 months after operation. Variables including the rate of perfect reduction by radiological analysis, the average distance of deviation between preoperative and postoperative CT measurements using Geomagic software and postoperative clinical examinations (e.g., mouth opening, occlusion) were investigated for outcome measurement. SPSS 19 was adopted for data analysis.

RESULTS

The average operation time was 180.60 min in the experimental group and 223.2 min in the control group. One week postoperatively, CT images showed that the anatomic reduction rate was 90.63% (29/32) in the experimental group and 68.57% (24/35) in the control group, revealing significant difference (X² = 4.919, p = 0.027). Geomagic comparative analysis revealed that the average distance of deviation was also much smaller in the experimental group than that in the control group (0.639 mm vs. 0.995 mm; t = 3.824, p < 0.001).

CONCLUSION

These findings suggest that virtual surgical planning can assist surgeons in surgical procedures, reduce operative time, and improve the anatomic reduction rate & accuracy, and thus of value in the diagnosis and treatment of condylar fractures.

Mini suture anchor: An effective device for reduction and fixation of displaced temporomandibular joint disc with intracapsular condylar fracture

PURPOSE

The main aim is to provide clinical reference for the application of mini suture anchor in the reduction and fixation of displaced temporomandibular joint (TMJ) disc with intracapsular condylar fracture.

METHODS

From October 2018 to October 2019, 21 patients (31 sides) with intracapsular condylar fractures and articular disc displacement from West China Hospital of Stomatology, Sichuan University were included. The selection criteria were: (1) mandibular condylar fractures accompanied by displacement of the TMJ disc, confirmed by clinical examination, CT scan and other auxiliary examinations; (2) indication for surgical treatment; (3) no surgical contraindications; (4) no previous history of surgery in the operative area; (5) no facial nerve injury before the surgery; (6) informed consent to participate in the research program and (7) complete data. Patients without surgical treatment were excluded. The employed patients were followed up at 1, 3, 6 and 12 months after operation. Outcomes were assessed by success rate of operation, TMJ function and radiological examination results at 3 months after operation. Data were expressed as number and percent and analyzed using SPSS 19.0.

RESULTS

All the surgical procedures were completed successfully and all the articular discs were firmly attached to the condyles. The articular disc sufficiently covered the condylar head after the fixation. The fixation remained stable when the mandible was moved in each direction by the surgeons. No complications occurred. The functions of the TMJ were well-recovered postoperatively in most cases. CT scan revealed that the screws were completely embedded in the bone without loosening or displacement.

CONCLUSION

Mini suture anchor can provide satisfactory stabilization for the reduced articular disc and also promote the recovery of TMJ functions.

Retro-Auricular Approach to the Fractures of the Mandibular Condyle: A Systematic Review

This systematic review was conducted to evaluate the retro-auricular trans-meatal approach (RA) to mandibular head fractures. Fractures of the mandibular head (8%) are a specific type of mandibular condyle fractures (34%). Despite numerous complications of conservative treatment, e.g., limited mobility and even ankylosis of the temporomandibular joint, as well as shortening of the mandibular ramus resulting in malocclusion, surgical intervention in this type of fracture is still problematic. The main problems with the dominant pre-auricular approach are the high risk of paralysis of the facial nerve and persistence of a visible scar. An attractive alternative is RA, which, despite its long history, has been described in English very few times, i.e., in only two clinical trials described in three articles in the last 21 years. According to these studies, RA gives a minimum of 90% of ideal positions of bone fragments and an always fully preserved function of the facial nerve in the course of long-term observation. RA allows the application of long screws for fixation, which provide good stabilization. In addition, new types of headless screws leave a smooth, non-irritating bone surface, and the immediate future may be dominated by their resorbable varieties. RA can, therefore, be treated as a very favorable access to fractures of the mandibular head, especially due to the protection of the facial nerve and the possibility of providing a stable and predictable fixation.

Biomechanical evaluation of type p condylar head osteosynthesis using conventional small-fragment screws reinforced by a patient specific two-component plate

BACKGROUND

The aim of this study was to evaluate via finite element analysis (FEA) the biomechanical behavior of conventional small-fragment screws reinforced by a patient-specific plate in type p condylar head.

METHODS

A finite element model of the mandible was created using Mimics 12.1 software. A type p condylar head fracture was simulated in the right condyle, and the left condyle was used as a control. Two patterns of fixation were investigated: conventional two-screw fixation and the same fixation system reinforced with a small, patient-specific plate. Surface models were imported into the software Ansys 5.7for further volume mesh generation.

RESULTS

The highest stress gradients were observed in the cortical layer of the lateral fragment, located near the screw. The conventional fixation method resulted in equivalent stresses 2 to 10 times greater than the reinforced method. Rigidity of fixation in the reinforced method increased up to 1.25-3 times compared to the conventional two-screw technique.

CONCLUSION

This study's findings suggest significant benefits in unfavorable biomechanical conditions from reinforcement of the standard two-screw fixation of condylar head fractures with a small, patient-specific plate acting as a washer.

Key points in surgical management of mandibular condylar fractures

Mandibular condylar fractures are among the most common facial fractures and some of the most difficult to manage. Opinions about the management of mandibular condylar fractures differ among surgeons. With the implementation of new technology, an increased understanding of fracture management, and better functional and morphological outcomes reported in the literature, open reduction and internal fixation is becoming many surgeons' preferred choice for the treatment of condylar fractures. Because surgical treatment of such fractures is complex, certain factors must be considered to achieve satisfactory outcomes. In this article, we summarise six key points in the management of mandibular condylar fractures: virtual evaluation of condylar fracture, a suitable surgical approach, good reduction, stable internal fixation, repair of the articular disc, and restoration of the mandibular arch width. We believe that these points will help to improve the prognosis of mandibular condyle fractures.

Management of maxillofacial trauma in the elderly: A European multicenter study

BACKGROUND/AIMS

Management of maxillofacial trauma in the geriatric population poses a great challenge due to anatomical variations and medical comorbidities. The aim of this study was to analyze the management variables, timing, and outcomes of facial fractures in elderly patients (aged 70 years or more) at several European departments of oral and maxillofacial surgery.

MATERIALS AND METHODS

This study was based on a systematic computer-assisted database that allowed the recording of data from all geriatric patients with facial fractures from the involved maxillofacial surgical units across Europe between 2013 and 2017.

RESULTS

A total of 1334 patients were included in the study: 665 patients underwent closed or open surgical treatment. A significant association (P < .005) was found between the presence of concomitant injuries and a prolonged time between hospital admission and treatment. The absence of indications to treatment was associated with comorbidities and an older age (P < .000005).

CONCLUSIONS

Elderly patients require specific attention and multidisciplinary collaboration in the diagnosis and sequencing of trauma treatment. A prudent attitude may be kept in selected cases, especially when severe comorbidities are associated and function is not impaired.

Management of mandibular condylar fractures in patients with atrophic edentulous mandibles

INTRODUCTION

Treatment of condylar fractures in patients with atrophic edentulous mandibles is a peculiar field that has been little considered in the literature. The aim of the study was to assess the demographic and clinical variables as well as management and outcome of mandibular condylar fractures in edentulous patients with atrophic mandibles that were treated at several European departments of oral and maxillofacial surgery.

METHODS

The data of all patients with fractures of the atrophic edentulous mandible from the involved maxillofacial surgical units across Europe between January 1, 2008, and December 31, 2017. Only patients that were diagnosed with condylar fractures of the edentulous atrophic mandible were included.

RESULTS

A total of 52 patients met the inclusion criteria and were included in the study: 79% of patients reported one or more comorbidities. Thirty-four unilateral neck or subcondylar fractures, 9 bilateral neck or subcondylar condylar fractures, 7 unilateral head condylar fractures, and 2 bilateral head condylar fractures were diagnosed. No treatment was performed in 37 cases, whereas in 4 patients a closed treatment was decided, and 11 patients underwent open reduction and internal fixation. Outcome was considered to be satisfying in 48 patients, with no complications.

CONCLUSIONS

The golden rule still remains that the diagnosis of a subcondylar or neck fracture in an edentulous patient should constitute an indication for open reduction and internal fixation. However, an appropriate choice of management options has to be individualized on a case by case basis, also depending on the patient consent.

Abduction of the condyle head leads to condylar resorption: A radiologic study in children with intracapsular fractures

OBJECTIVE

This study aimed to explore and make an understanding of absorption existed in children with intracapsular fractures.

METHODS

The sample was composed of all children (less than 12 years) who presented with intracapsular fractures within a 5-year period (January 2011 to April 2016). Data about age, gender, date of injury, dates of admission and discharge, transfer and/or referral by other clinics or local facilities, mechanism of trauma, location and pattern of fracture, associated injuries, centimeter of mouth opening, treatment methods, image date of pre- and post-treatment (including time of review), position of condylar head in pre-treatment or post-treatment, and absorption of condylar head in pre-treatment or post-treatment were recorded and analyzed. Data analysis included the Chi-Square test, the Fisher exact test, and the t-test. Logistic regression analysis was utilized to control the confounding variables. Probabilities of p less than 0.05 were considered statistically significantly different.

RESULTS

In the 5 years records retrieved during this study, 93 children patients sustained a total of 140 condylar head fractures. Statistical analysis revealed that abduction of condylar process in post-treatment was highly related to the condylar absorption. Patients associated with other mandibular fractures were highly related to abduction of condylar process. Patients with condylar head fractures, the closer to the medial of the condylar process, the higher the risk of abduction of the condyle. No matter what kind of treatment method is used, it is very difficult to reverse the abduction of condylar process in children patients with intracapsular fractures efficaciously.

CONCLUSION

Abduction of condylar process in post-treatment was highly related to the condylar absorption. Patients associated with other mandibular fractures were highly related to abduction of condylar process. Children patients who presented with condylar head fractures, the closer to the medial of the condylar process the higher the risk of abduction of the condyle. Neither surgery nor conservative treatment can recover the abduction of condylar process efficaciously.

The "European zygomatic fracture" research project: The epidemiological results from a multicenter European collaboration

PURPOSE

Fractures of the zygomaticomaxillary complex (ZMC) are common injuries that may lead to loss of an aesthetically pleasing appearance and functional impairment. The aim of this study was to analyze the demographics, causes, characteristics, and outcomes of zygomatic fractures managed at several European departments of oral and maxillofacial surgery.

MATERIALS AND METHODS

This study is based on a multicenter systematic database that allowed the recording of all patients with ZMC fractures between 1 January 2013 and 31 December 2017. The following data were recorded: gender, age, personal medical history, etiology, side of zygomatic fracture, classification of ZMC fracture, associated maxillofacial fractures, symptoms at diagnosis, type of performed treatment, and sequelae/complications.

RESULTS

A total of 1406 patients (1172 males, 234 females) were included in the study. Statistically significant correlations were found between assault-related ZMC fractures and the A3 class (p < .0000005) and between Infraorbital Nerve (ION) anesthesia and B class (p < .00000005).

CONCLUSION

The most frequent cause of ZMC fractures was assault, followed by falls. The most frequently involved decade of age was between 20 and 29 years. The decision and type of surgical treatment of ZMC fractures depends on several issues that need to be considered on a case by case basis.

Functional Treatment of a Child with Extracapsular Mandibular Fracture

Condylar fractures are among the most frequent fractures in the context of traumatic lesions of the face. The management of condylar fractures is still controversial, especially when fractures occur in children: if overlooked or inappropriately treated, these lesions may lead to severe sequelae, both cosmetic and functional. The therapy must be careful because severe long-term complications can occur. In this case report, the authors present a case of mandibular fracture in which the decision between surgical therapy and functional therapeutic regimen may be controversial due to the particular anatomy of the fracture line and the age of the patient.