Treatment of low subcondylar fractures--a 5-year retrospective study

Biomechanical evaluation of various rigid internal fixation modalities for condylar-base-associated multiple mandibular fractures: A finite element analysis

Condylar-base-associated multiple mandibular fractures are more prevalent than single ones. Direct trauma to mandibular symphysis, body or angle are prone to induce indirect condylar fracture. However, little is known about the effects of various rigid internal fixation modalities in condylar base for relevant multiple mandibular fractures, especially when we are confused in the selection of operative approach. Within the finite element analysis, straight-titanium-plate implanting positions in condylar base contained posterolateral zone (I), anterolateral zone (II), and intermediate zone (III). Von Mises stress (SS) in devices and bone and mandibular displacement (DT) were solved, while maximum values (SSmax and DTmax) were documented. For rigid internal fixation in condylar-base-and-symphysis fractures, I + II modality exhibited least SSmax in screws and cortical bone and least DTmax, I + III modality exhibited least SSmax in plates. For rigid internal fixation in condylar-base-and-contralateral-body fractures, I + III modality exhibited least SSmax in screws and cortical bone, I + II modality exhibited least SSmax in plates and least DTmax. For rigid internal fixation in condylar-base-and-contralateral-angle fractures, I + III modality exhibited least DTmax. The findings suggest that either I + II or I + III modality is a valid guaranty for rigid internal fixation of condylar base fractures concomitant with symphysis, contralateral body or angle fractures.

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.

High Submandibular Anteroparotid Approach for Open Reduction and Internal Fixation of Condylar Fracture

Aim

There are several techniques for the treatment of mandibular condylar fractures. This is the first report of the high submandibular anteroparotid approach for open reduction and internal fixation of condylar fracture.

Materials and Methods

A 41-year-old woman fell indoors and injured her face. She was referred to our department for detailed examination and treatment of a suspected mandibular fracture. X-ray and computed tomography showed a right mandibular condylar base fracture and lateral dislocation of the fracture fragment. Open reduction and internal fixation procedures were performed for a right mandibular condylar fracture under general anesthesia. The mandibular ramus was reached by approaching from the inferior margin of the mandible, delaminating the masseter fascia posteriorly, and bypassing the anterior margin of the parotid gland. Once the fractured bone was reached, reduction and fixation were performed.

Results

We have achieved good results by the high submandibular anteroparotid approach, which is minimally invasive and simple, to reduce and fix condylar fractures. With this approach, no facial artery or retromandibular vein was encountered, and the mental stress for the surgeon was minimal. Postoperative wound infection, parotid gland complications such as parotitis and salivary fistula, facial nerve dysfunction such as facial paralysis, and esthetic disorders such as scarring were not observed.

Conclusions

Although it is necessary to examine more cases in the future, the high submandibular anteroparotid approach may be useful as a new approach for open reduction and internal fixation of condylar fractures.

Does the Retromandibular Transparotid Approach Provide Quicker Access to Fracture of Mandibular Subcondyle Compared With the Retromandibular Transmasseteric Anterior Parotid Approach?

PURPOSE

Limited studies are available in the literature comparing various surgical approaches for the management of condylar fractures, and those comparing different types of retromandibular approaches are even fewer in number. This study aimed to compare the efficacy of 2 variants of the retromandibular approach-retromandibular transmasseteric anterior parotid (RMTMAP) and retromandibular transparotid (RMTP) in terms of exposure time, blood loss, facial nerve palsy, sialoceles or parotid fistula formation, infection, and esthetics of scar tissue.

PATIENTS AND METHODS

A randomized controlled trial was designed in patients with mandibular subcondylar fractures requiring operative intervention. Patients were randomized into 2 groups based on a computer-generated randomization table. Group A included 37 cases, treated with the RMTMAP approach, and group B included 38 cases treated with the RMTP approach. The primary outcome variable was exposure time. Secondary outcome variables were blood loss during exposure, complications like facial nerve palsy, sialocele formation, surgical site infection, and scar esthetics. All patients were followed for 3 months. Collected data were analyzed using the χ² and analysis of variance tests.

RESULTS

The mean exposure time for fractures treated with the RMTMAP approach and RMTP approach was 21.08 ± 9.18 and 13.57 ± 6.09, respectively (P < .05). The mean blood loss for RMTMAP and RMTP approach was 11.75 ± 5.11 and 9.9 ± 3.77 mL, respectively (P = .078). No facial nerve injury was seen in patients treated with the RMTMAP approach, whereas 3 (7.8%) patients in the RMTP group had transient facial nerve injury (P = .08).

CONCLUSIONS

This study concludes that the RMTP approach provides quicker access to the condyle as compared with the RMTMAP approach. However, the incidence of transient facial nerve injury was more in the RMTP approach. Except for reduced blood loss in the RMTP approach, all other parameters were comparable in both the approaches.

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.

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.

Evaluation of Complications Following a Trans-masseteric Antero-parotid Approach for Patients with Sub-condylar Fractures of Their Temporomandibular Joint. A Retrospective Study

Sub-condylar fractures of the temporomandibular joint can be treated by an extraoral or intraoral approach. Trans-masseteric antero-parotid approach (TMAP) is an extraoral approach utilising a retromandibular incision. The authors evaluated patients' status and any complications of using TMAP from the years 2013-2017. There were 39 patients (44 fractures). When using TMAP, in 43 fractures the fragments were favourably positioned, in one case the position was compromised. Of the complications, postoperative palsy of the facial nerve was reported 6.8% - in all cases this was only temporary. Late occlusion had an equal number of complications (in 2 cases this was as a result of an infectious complication of the wound, and in 2 cases due to resorption of the proximal fragment). Muscular pain and dysfunction of the temporomandibular joint following trauma were observed consistently in 6.8% of patients. Sialocoele, a non-conforming scar, and infectious complications were observed in 4.5% of patients. TMAP allows rapid surgical performance, with a good view for perfect repositioning and fixation of fragments of sub-condylar fractures of the temporomandibular joint. The complications associated with this approach are, for the most part, temporary, the aesthetic handicap of a scar is considered by patients to be acceptable. Overall, it is possible to evaluate retromandibular TMAP as safe, and the authors recommended it for treatment of sub-condylar fractures of the mandible.

Unilateral absence of mandibular condyle in a Bronze Age male skeleton from Portugal

In 2009, a pit burial dated to the Bronze Age was excavated in Monte do Gato de Cima 3 (Portugal). The purpose of this paper is to describe the pathological absence of the left mandibular condyle noted in an adult male skeleton and to discuss possible diagnoses, including subcondylar fracture, cystic defect, congenital absence, condylar aplasia and mandibular condylysis. The most likely explanation for the pathological alteration is subcondylar fracture with non-union. Although the occurrence of non-union and slight osteoarthritic alterations in the left glenoid fossa were evident, this mandible was likely functional, as can be inferred from dental wear and muscle attachment sites. This trauma probably occurred before adult age when remodelling capacity is still high. Thus, bones and muscles adequately compensated for the trauma and only minor asymmetry developed. Consequently, this injury seems not to have greatly influenced masticatory functions. This is in accordance with clinical data, which demonstrate that, in growing patients, conservative treatment (non-surgical) results in good remodelling and patient recovery. In addition, in the few paleopathological cases published, the healing capacity of these types of mandibular fractures seems to be good, as can be inferred by evidence from the bone.

Double unilateral, bilateral, and multiple mandibular fractures: an observational study

PURPOSE

Double and multiple mandibular fractures are associated to high morbidity and functional damage. This study aimed to evaluate the characteristics and outcomes of double unilateral, bilateral, and multiple mandibular fractures.

METHODS

A 7-year observational retrospective analysis was performed, and the injury-related data were collected from the medical records. Statistical analysis was performed using Fisher's exact test (p < 0.05).

RESULTS

In this period, 283 patients showed mandibular fractures. Of them, 83 (29.7%) had double or multiple mandibular fractures and were included in the study. Double bilateral fractures were more prevalent than multiple or double unilateral. Multiple fractures presented significant association with the combination of load-bearing and load-sharing fixation protocols. Most cases (94.0%) applied at least one type of internal fixation system. However, there was a positive association between condylar fractures and non-surgical treatment (p < 0.01). Moreover, mandibular body fractures were associated with load-bearing fixation (p < 0.01). In 56 cases, no complications were observed (67.5%). Complications were divided into treatment failure (10.8%) and transitory or minor complications (21.7%). There was no statistical association between complications and fracture pattern, fracture-tooth relation, and treatment modality.

CONCLUSION

Double and multiple mandibular fractures represented almost one third of all mandibular fractures, and regardless to treatment protocol, there was no difference about complications. Moreover, although a considerable complication rate was found, most of them were minor or transitory.

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.

Open reduction and internal fixation of extracapsular mandibular condyle fractures: a long-term clinical and radiological follow-up of 25 patients

Background

During the last 2 decades, many studies on the treatment of mandibular condyle fracture have been published. The incidence of mandibular condyle fractures is variable, ranging from 17.5% to 52% of all mandibular fractures. This retrospective study evaluated the long-term clinical and radiological outcomes after surgical treatment of 25 patients with a total of 26 extracapsular condyle fractures.

Methods

We used 2 types of surgical approaches, the retromandibular retroparotid or preauricular approach. Three kinds of rigid internal fixation plates were used—single plate, double plate, and trapezoidal plate. The following post-operative clinical parameters were evaluated: dental occlusion, facial nerve functionality, skin scarring, and temporomandibular joint functionality. All patients underwent post-operative orthopanoramic radiography and computed tomography. The patients were also monitored for complications such as Frey’s syndrome, infection, salivary fistula, plate fracture, and permanent paralysis of the facial nerve; the patient’s satisfaction was also recorded.

Results

Of the 25 patients, 80% showed occlusion recovery, 88% had no facial nerve injury, and 88% presented good surgical skin scarring. The patients showed early complete recovery of temporomandibular joint functionality and 72% of them were found to be asymptomatic. The postoperative radiographs of all patients indicated good recovery of the anatomical condylar region, and 80% of them had no postoperative complications. The average degree of patient satisfaction was 8.32 out of 10. Our results confirm that the technique of open reduction and internal fixation in association with postoperative functional rehabilitation therapy should be considered for treating patients with extracapsular condylar fractures.

Conclusion

The topic of condylar injury has generated more discussion and controversy than any other topic in the field of maxillofacial trauma. We confirm that open reduction and internal fixation is the treatment of choice for patients with neck and sub-condylar mandibular fractures.