Clinical and radiological outcomes of transoral endoscope-assisted treatment of mandibular condylar fractures

Transoral endoscopic assisted reduction and internal fixation of mandibular condylar neck fractures with short condylar segment

This study aimed to assess the reliability and safety of transoral endoscopic-assisted reduction internal fixation (TERIF) for treating short-segment condylar neck fractures (CNF), including hardware removal. Patients with displaced CNF and short condylar segments treated using TERIF were included in the study. Clinical evaluation covered dental occlusion, range of mouth opening, deviation during mouth opening, protrusion, laterotrusion, pain, and chewing. Radiological evaluation was used to assess fracture displacement, angulation, head dislocation, postoperative reduction, fixation stability, and bone healing. The same technique was used to treat 15 patients with 18 CNF and short condylar segments. Hardware removal was performed for nine fractures in eight patients after fracture healing using the same approach. All patients regained satisfactory, pain-free mouth opening with no deviation and complete bone healing. Computed tomographic images displayed adequate reduction and stable fixation during the follow-up period for all patients. No temporary or permanent facial nerve impairment occurred in any of the patients. TERIF is a reliable and safe treatment for CNF with short condylar segments, even in the presence of head dislocation, medial override, and malunited fractures; hardware can be safely removed after healing using the same approach.

A Comparative Assessment of Right-Angle Screwdriver Versus Conventional Screwdriver for Orthognathic Surgeries

Background Bilateral orthognathic surgery is one of the unique and challenging orthognathic surgeries that gained popularity after numerous modifications to the techniques. Using linear equipment inside the oral cavity might lead to malalignment or structural weakness due to incorrect placement, making the ramus osteotomy more difficult. By directly positioning the instrument perpendicularly over the mandibular ramus region, a right-angle drill can help promote a more ergonomic approach. Objectives The primary objective was to compare the efficacy of a right-angle screwdriver over a conventional screwdriver for orthognathic surgery using clinical parameters. The second objective was to assess the ease of fixation, the ease of osteotomy, and the time taken for the surgery in both groups. Methods This prospective observational study, comparing the effectiveness of conventional and right-angle screwdrivers for orthognathic surgery, was carried out on 12 patients. A split-mouth design was chosen. For the 12 patients, a right-angle screwdriver was used to secure the right mandibular plate and screw, while a traditional straight handpiece was used to fix the left plate and screw. Clinical parameters such as the ease of osteotomy, the ease of fixation, the time taken for fixation, and the postoperative angulation of the screw in relation to the bone with cone beam computed tomography were evaluated. The procedure was communicated to the patients, followed by obtaining written informed consent. Result Statistical analysis was done using descriptive and inferential statistics using an independent sample t-test and an unpaired t-test. IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, NY, USA), was used. The level of significance was set at a p-value of <0.05. Compared to a conventional screwdriver, the right-angle screwdriver made osteotomies and fixations easier for 12 patients and also required less surgical time. Statistically, it was shown that ease of fixation had a statistically significant difference among right-angled and conventional screwdrivers (p-value < 0.001), whereas time taken had an insignificant difference (p-value 0.13). The angulation of screw fixation with the right angle showed a consistent result of fixation perpendicular to the bone when compared with conventional screwdrivers providing stable fixation, which was statistically significant (p-value < 0.001). Conclusion Compared to the conventional screwdriver used in orthognathic procedures, the right-angle screwdriver ensures solid fixation and eliminates the challenges encountered while drilling and screwing posteriorly positioned screws.

Endoscopic-assisted intraoral approach for mandibular condyle fracture management: A systematic review and meta-analysis

OBJECTIVE

Surgical innovation led to an endoscopic-assisted intraoral approach for managing condyle fractures. The purpose of this systematic review is to purview the role of the endoscope and determine the range of information, summarizing the evidence for the benefit of surgeons on an endoscopic-assisted intraoral approach.

STUDY DESIGN

A literature search was conducted in PubMed, Google Scholar, Semantic Scholar, and Cochrane Library databases for studies mentioning the endoscopic intraoral approach for managing mandibular condylar fractures. Outcomes include the role of the endoscope, challenges, adjunct armamentarium, duration, and complications associated with the transoral and transbuccal approach for screw fixation. The meta-analysis was conducted with prevalence estimates and standardized means using STATA.

RESULTS

Thirty-nine studies were included. A 30° angulated, 4-mm-thick endoscope was the most commonly used endoscope. Two mini plates were most commonly used for fixation. Facial nerve weakness was higher in the transbuccal approach (1.24%) than in the transoral approach (0.8%). Pooled analysis (6 studies) showed that the duration of the surgical procedure was less in the transoral approach compared with the transbuccal approach for screw fixation. The bailout was 1.49%.

CONCLUSIONS

The endoscopic-assisted intraoral approach is reliable for condylar fracture management. The transoral and transbuccal approaches can be used for screw fixation with comparable outcomes.

How far we have come with the Management of Condylar Fractures? A Meta-Analysis of Closed Versus Open Versus Endoscopic Management

Background

The treatment approaches for condylar fractures of the mandible include functional, closed reduction and open reduction-internal fixation. Recently endoscopic management of condylar fractures has been emphasized in the literature. We systematically review the studies comparing closed versus open versus endoscopic-assisted condyle fracture management with regard to the indications, effectiveness and complications of each modality.

Methods

A total of 11 articles were selected based on the inclusion and exclusion criteria from PubMed, Cochrane and clinical trials.gov. Differences in means and risk ratios were used as principal summary measures with p value < 0.05 as significant. For detection of any possible biases in sample sizes, the OR and its 95% CI for each study were plotted against the number of participants. Chi-square test, I2 test and the Cochrane bias tool were used to assess the bias in and across studies.

Results

Except for deviation on opening there was no significant difference between open versus closed treatment of condylar fractures. Endoscopic approach and open surgical approaches differed only in terms of operating time and TMJ pain. There was no significant difference in facial nerve injury among the two groups.

Discussion

Closed reduction is particularly indicated for minimally displaced fractures; for moderate to severe displacement, open reduction is preferred. Open reduction can also be preferred over endoscopic approaches as there is no significant advantage of using latter. Limitations of the study included specific treatment according to the site of fracture not addressed, limited data regarding pediatric condylar fracture, lack of homogenous classification schemes, etc.

Minimally Invasive "Trocar-Free" Approach for Rear Mandibular Fractures Management

ABSTRACT

The request of minimally invasive surgery is progressively expanding the indications of endoscopically assisted intraoral access for mandibular traumas. The aim of our study is to assess how much the use of the angled drill may affect the outcome of patients treated for rear mandibular fracture.In our retrospective case-control trial we enrolled 36 patients with mandibular rear fractures treated through endoscopically assisted intraoral access. Eighteen patients were treated by using an angled drill "trocar free," and 18 treated by linear drills placed through trocars. Surgical times, hospitalization times (HT), and major complications rate were compared between the 2 groups.Group 1 showed a significant reduction in HT (1.72 versus 2.22 days, P = 0.024) and an increase in the surgical times (3.0 versus 2.53 hours, P = 0.019). Significant reduction of total amount of complication was seen in group 1 versus group 2 (P = 0.007).The "trocar free" approach allowed by angled drills, in our hands, greatly reduces the invasiveness of the surgery resulting in a significant reduction in HT and smaller share of vascular-nervous sequelae. Our results suggest the "trocar free" approach as a valuable choice when indicated for the treatment of rear mandibular fractures.

Extracapsular Condylar Fractures Treated Conservatively in Children: Mechanism of Bone Remodelling

OBJECTIVE

This study aims to reveal the reconstruction process in pediatric patients with extracapsular condylar fractures after conservative treatment. We clarify that the "upright" position (or "recontouring" or favorable prognosis) of condyles is not a result of the anatomical reduction of the deviated condylar processes but originates from the remodeling of the skeleton. We also explore the related mechanism.

METHODS

The sample consisted of 27 pediatric patients aged less than 12 years who presented with extracapsular condylar fractures and were treated conservatively within an 8-year period (June 2011-April 2019). Data on the age, gender, date of injury, mechanism of trauma, location and pattern of mandibular condylar fracture and associated injuries and treatment methods of the patients were obtained. The process of bone remodeling in condyles was also recorded and analyzed.

RESULTS

The 27 children in this study sustained 33 extracapsular condylar fractures over the 8-year period of record retrieval. Amongst these fractures, 8 (24.2%) and 25 (75.8%) were condylar neck and condylar base fractures, respectively. Deviation and green-stick fractures were the predominant types and accounted for over 3 quarters of the condylar neck and base fractures (28, 84.8%), followed by dislocation fracture (3, 9.1%), displacement fracture (1, 3.0%), and non-displaced fracture (1, 3.0%). The period of follow-up ranged from 2 days to 257 days (average, 58.78 days). Only 1 patient with bilateral extracapsular condylar fractures showed vertically reconstructed condyles, which indicates an upright position of the condylar processes. One patient showed less angulation after treatment than before treatment, 1 patient revealed greater angulation after treatment than before treatment and all other patients (20 patients) showed the same angulation pre- and post-treatment. Both patients with only extracapsular condylar fractures showed no obvious deviations in dentition and facial asymmetry after their injury and treatment. The shortest and longest times observed for bone remodeling were 33 and 256 days, respectively. Children whose condylar head remained completely or at least partly inside the glenoid fossa showed satisfactory remodeling results during follow-up. Computed tomography scan during follow-up generally showed bone regeneration in the lateral condyle articular surface and the medial portion of the ascending ramus and bone resorption in the displaced direction (ie, the medial condyle head became sharp). Condylar heads displaced completely outside of the glenoid fossa showed serious shortening of the ascending ramus, and no obvious bone remodeling was observed. Only 1 patient with bilateral extracapsular condylar fractures showed a normal contour (ie, a vertically reconstructed condyle reflecting the upright position of the condylar processes) after 8 months.

CONCLUSION

Stress stimulation originating from the glenoid fossa and ascending ramus of the mandible is a prerequisite for good condylar reconstruction. Conservative treatment could be carried out if the condylar head remains completely or at least partly inside the glenoid fossa. When the condylar head is dislocated completely outside the glenoid fossa, the glenoid-condylar relationship ceases to exist, joint function is lost and the height of the ascending ramus is significantly reduced. In this case, open reduction may be suitable.

Endoscopic surgery versus open reduction treatment of mandibular condyle fractures: A meta-analysis

The aim of the study was to compare open reduction with internal fixation (ORIF) and endoscopic open reduction with internal fixation (EORIF) of condylar fractures (CF) in adults in terms of reducing both needing of reoperation and/or facial nerve injury. An electronic search was undertaken (PubMed/MEDLINE, Web of Science, SCOPUS, and The Cochrane Library). The inclusion criteria were full text, published from their inception to June 2020, clinical trials, randomized or not, and retrospective studies, that compared ORIF and EORIF. The estimates of an intervention were expressed as the risk ratio (RR). From the 1338 articles found, 5 publications were included. There was no statistically significant difference between ORIF and EORIF regarding needing of reoperation (RR = 2.46, p = 0.42) or facial nerve injury (RR = 0.45, p = 0.14). Meta-analysis suggests that there is no difference between open reduction with internal fixation (ORIF) and endoscopic open reduction with internal fixation (EORIF) of condylar fractures (CF) regarding facial nerve injury risk or need for reoperation.

Endoscopically Assisted Open Reduction and Internal Fixation of Sub-Condylar Fractures: Debunking Some of the Myths

Endoscopically assisted open reduction and internal fixation has cumulate advantages over both open and closed techniques. Even though, this approach had not become popular. The study intended to summarize the outcomes and complications from the first 12 consecutive cases of sub condylar fractures that treated by endoscope and trans-buccal trocar. All patients experienced improvement in mouth opening. No postoperative malocclusion was noticed. The learning curve was assessed subjectively regarding the use of the endoscope and objectively by operating time reduction. The significant decrease in operating time and the ease of handling the endoscope were already noticed after the 5th operation. The mean time for endoscopically assisted open reduction and internal fixation in our study was 180 minutes, which was the same as for external approaches open reduction and internal fixation for sub-condylar fracture cases. No special designed instruments except an endoscope and a trans-buccal trocar were used. We can conclude that the learning curve for this technique is not as steep as it was thought to be, and it can be mastered after a relatively small number of operations. There is no difference in mean operation time comparing to external approaches. No need for special designed instruments.

Endoscopic-Assisted Intraoral Open Reduction Internal Fixation of Mandibular Subcondylar Fractures: Initial Experiences from a Tertiary-Care Maxillofacial Center in India

Management of condylar fractures is a highly controversial and debatable area. Open reduction and internal fixation (ORIF) using an extraoral approach has certain benefits over the nonsurgical treatment. Risk of damage to the facial nerve and an extraoral scar remains constant deterrents. An endoscopic-assisted ORIF offers an intraoral approach, thus eliminating consequences such as scarring. Though this technique offers unparalleled advantages, it is associated with a steep learning curve. Surgical results improve only with patience and experience. Patients with condylar fractures reported to SDM Craniofacial Unit, Dharwad, India, from 2013 to 2015 are included. Patients were treated with endoscopic-assisted ORIF and were evaluated for functional outcomes that included occlusion, maximal interincisal opening, and deviation of mouth and complications such as facial nerve pareses, postsurgical infection, and morbidity. Fifteen patients included in the study: 4 left sided and 11 right sided fractures. Nine patients had associated other mandibular fracture. Mean age of the patients was 28.2 years. Mean mouth opening at the end of 1 week, 6 weeks, and 6 months was 32.6, 37.8, and 40.5 mm, respectively. Transient facial nerve pareses were noted in one patient, and an extraoral draining sinus was noted in another. Endoscopic-assisted ORIF has a definite scope in management of condylar fractures. Results are more predictable with appropriate case selection due to a steep learning curve and intraoperative technical challenges. An initial experience in ORIF using extraoral approaches would greatly benefit a surgeon in utilizing this novel and alternate tool.