Surgical treatment of mandibular condyle fractures using the retromandibular anterior transparotid approach and a triangular-positioned double miniplate osteosynthesis technique: A clinical and radiological evaluation of 124 fractures

Application of Crus of Helix Incision Through the Posterior Parotid Gland Approach in the Mid-Level or High-Level Mandibular Condylar Fractures

OBJECTIVE

This study is to explore the clinical effect of crus of helix incision through the posterior parotid gland approach in the treatment of Mid-or High-Level mandibular condylar fractures.

METHODS

From September 2020 to June 2023, we performed incision reduction internal fixation of 23 patients with mid-level or high-level fractures of the mandibular condylar through the approach of the posterior parotid gland, and observed the effect of the operation.

RESULTS

After a follow-up period of 6 to 12 months, all patients showed no signs of postoperative facial paralysis or salivary gland fistula. In addition, satisfactory scars were observed in the operation area, and the occlusion function had recovered well.

CONCLUSION

The approach of using a crus of helix incision through the posterior parotid gland proved to be an effective method for treating mid-level or high-level fractures of the condylar fractures. This technique offers several advantages, including adequate exposure, minimal facial nerve injury, ease of incision and reduction, inconspicuous scarring, and a more concealed incision.

A single-centre retrospective 10-year experience of the rhombic 3D condylar fracture plate for open reduction and internal fixation of condylar neck and base fractures

Fractures of the mandibular condyle account for a significant proportion of mandibular fractures. The specific functional loads require particular specifications for the implant design used for open reduction and internal fixation of such fractures. The clinical and radiographic outcomes in patients treated using a single rhombic 3D condylar fracture plate for open reduction and internal fixation at a single institution, and who fulfilled the inclusion and exclusion criteria, are presented. The primary outcome variables were: occlusion, maximum interincisal distance and mandibular excursion at 1, 3, and 6 months postoperatively, and radiographic measurements for mandibular height and gonion angle. In total, 263 patients were included, of whom 173 (65.8%) were male and 90 (34.2%) female. The mean age was 40.4 ± 18.9 years. There was satisfactory occlusion in 98.9% of patients at the 6-month follow-up, and a significant improvement in all parameters for mandibular excursion (p < 0.001), with a reduced ramus height and an increase in the gonion angle on the fractured side. Excellent clinical and radiographic results were achieved using the rhombic-shaped implant, deeming it appropriate for the osteosynthesis of mandibular condyle fractures.

The "low preauricular" transmasseteric anteroparotid (TMAP) technique as a standard way to treat extracapsular condylar fractures

Condylar fracture treatment is a debated topic among maxillofacial surgeons. Various surgical techniques are used today, each one with advantages and disadvantages. The aim of this study is to present and evaluate our technique adopted for treatment of any type of extracapsular condylar fractures. Between 2020 and 2022, 16 condylar fractures were treated. In two patients with bilateral condylar fractures, the present technique was compared to the mini-retromandibular approach. All the patients were checked for clinical and radiological outcomes, facial nerve injury, scar visibility and presence of salivary complications. Dental occlusion was always restored, and facial nerve damage or salivary disorders were not observed. The skin incision, limited to the caudal two-thirds of the auricle, made the scar almost invisible and greatly improved the surgical field in the condylar neck area, facilitating the treatment. The proposed technique provides easier internal fixation for both neck and base condylar fractures with good cosmetic results, ensuring better protection of the facial nerve and parotid gland. The surgical technique described has not shown disadvantages in terms of operational difficulty, results, and complications. This novel surgical technique could represent a new choice in the treatment of extracapsular condylar fractures, although further studies are needed to support this new proposal.

Innsbruck-style Retromandibular Anterior Trans-parotid Approach for Condylar Fractures: A Retrospective Review of 39 Fractures

The retromandibular anterior trans-parotid (RAT) approach and a triangular-positioned double mini-plate osteosynthesis (TDO) technique have been reported from Innsbruck Medical University. This minimally invasive technique involves direct visualization of the condyle and is associated with lower incidence of facial palsy.

Methods

A retrospective review was performed on the RAT approach and TDO technique conducted by a surgeon and team at two hospitals in Tokyo during a period of 3 years and 10 months.

Results

This technique was performed on 35 patients with 39 condylar fractures. Sixty-nine percent of cases were due to accidental fall, 17% to traffic accidents, and 9% to sports. Furthermore, 92% cases were condylar base fractures. Nighty-seven percent of cases achieved good occlusion. The mean maximum mouth opening was 49 ± 1.3 mm. Postoperatively, facial palsy developed in three patients (7.7%), and two of them developed Frey syndrome at approximately 2.5 years postoperatively (5.1%). All patients completely recovered within 3 months postoperatively. One case each of salivary fistula, visible scar, and condylar resorption was found (2.6%). No case of massive bleeding during surgery, hematoma, or TMJ pain after surgery was found.

Conclusion

This technique could achieve good occlusion with low incidence of complications and could contribute to early social reintegration among patients.

Evaluation of internal fixation techniques for extracapsular fracture: A finite element analysis and comparison

BACKGROUND AND OBJECTIVES

This study explored the optimal plates and screws fixation for extracapsular fracture by finite element analysis, and provided a biomechanical basis for clinical treatment.

METHODS

Four extracapsular fixation models were built and evaluated: A. One single straight four-hole plate with two bi-cortical screws on both sides and two mono-cortical screws in the middle; B. One single straight four-hole plate with four bi-cortical screws; C. Two straight four-hole plates, each with two bi-cortical screws on both sides and two mono-cortical screws in the middle; D. One L-shape four-hole plate in the back and one straight four-hole plate in the front, each with two bi-cortical screws on both sides and two mono-cortical screws in the middle. Displacements of fractured bone blocks and stress of plates, screws, cortical and cancellous bone and the deformation of plates were analyzed by finite element analysis to investigate their stability in clinical using.

RESULTS

Groups A and B showed larger displacements of the fractured bone block, greater deformation of plates and higher risk of the plate breakage during masticatory motion. Groups C and D exhibited the minimum displacements of the fractured bone block, the stress distribution within the safe range and less deformation of the plates. In addition, double plates fixation and bi-cortical screws exceeded single plate fixation and mono-cortical screws in stability, respectively, while an L-shape plate exhibited no significant differences in the stress dispersion and the displacement reduction.

CONCLUSIONS

Double plates fixation of the extracapsular condylar fracture was a safe and stable way and bi-cortical screws should be selected as far as possible.

Comparison between 3D delta plate and conventional miniplate in treatment of condylar fracture: A randomised clinical trial

The aim of the study was to conduct a randomized clinical trial comparing the efficacy of standard non-compression miniplate and 3-dimensional (3D) titanium plate in the open reduction internal fixation (ORIF) of the mandibular condylar fractures. Patients who underwent open reduction of mandibular condylar fracture were recruited for the study. The patients satisfying the inclusion criteria were randomly assigned to two groups in a 1:1 ratio. Group A comprised patients treated using conventional miniplates, and Group B comprised patients treated using 3D Delta Plate. Informed consent was provided. All the patients underwent ORIF under GA via retromandibular approach. The sample size was set at 20 participants, with 10 participants in each group who were randomly allocated. Our study showed that patients in Group A had a significant statistical difference operating time (141.20 ± 2.59 min) than that of Group B (117.2 ± 9.63 min). Mouth opening was significantly greater in the 3^rd-month follow-up in Group B (mean = 42.40 ± 1.82) compared to Group A (mean = 35.80 ± 1.30). Biting efficiency in Group B was observed to be clinically and statistically better compared to Group A (P = 0.012). Wound dehiscence was managed efficiently by judicious use of antibiotics and wounds were free of any signs of infections or discharge in the consecutive follow-ups. No plate removal was required in either group. Patients treated with 3D delta plates have superior outcomes with regard to operation time, mouth opening, and biting efficiency compared with miniplates. Hence, it can be concluded that the triangular shape of the 3D Delta plate allows the stress distribution to be superior and multidimensional, leading to better post-operative stability, faster healing, and reduced complications.

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.

The Retromandibular Transparotid Approach for Reduction and Internal Fixation of Mandibular Condylar Fractures

Introduction:

The retromandibular transparotid approach is most useful for condylar and subcondylar fractures and provides the best access to the joint and ascending ramus. The study aims at evaluating the ease of access and outcomes encountered on using the retromandibular transparotid approach to access the fracture site for the open reduction and internal fixation (ORIF) of condylar and sub-condylar fractures.

Materials and Methods:

An observational clinical study was carried out among 10 patients with unilateral and bilateral condylar fracture requiring ORIF. Maximal interincisal mouth opening, facial swelling, occlusal discrepancy, facial nerve injury, scar formation, and acceptability and complications including wound dehiscence, infection, and sialocele/salivary fistula were assessed and measured preoperatively and postoperatively.

Results:

There was a notable improvement in mouth opening and facial nerve weakness. Postoperative intermaxillary fixation was done with selective patients who had a discrepancy in their occlusion. Preoperatively, swelling was present in four patients (40%) out of 10 patients studied. There was no incidence of sialocele/salivary fistula in any of the cases studied.

Conclusion:

Retromandibular transparotid incision is technique sensitive and thorough knowledge about the retromandibular area is must for good results and minimal morbidity. The cosmetic results are good in this approach, as well as the facial nerve injury were less in this without any permanent damages.

Surgical approaches for condylar fractures related to facial nerve injury: deep versus superficial dissection

The aim of this study was to investigate the probability of facial nerve injury (FNI) in the treatment of condylar neck and subcondylar fractures (CN/SCFs) with percutaneous approaches and to identify factors predicting FNI. The data of 80 patients with 87 CN/SCFs were evaluated retrospectively. The primary outcome was FNI occurrence. The predictor variables were age, sex, aetiology, alcohol consumption, fracture site and pattern (dislocation or not), concomitant fractures, time interval to surgery, surgeon experience, plate type, and the dual classification of percutaneous approaches. The approaches were classified based on whether subcutaneous dissection traversed the marginal mandibular branch (MMB) deeply (deep group: submandibular and retroparotid approaches) or superficially (superficial group: transparotid, transmasseteric anteroparotid (TMAP), and high cervical-TMAP approaches). Twenty-two patients (27.5%) suffered FNI, of whom two in the deep group had permanent paralysis of the MMB. In the multivariate logistic regression model, deeply traversing surgery approaches (odds ratio 12.4, P=0.025) and the presence of a dislocated fracture (odds ratio 6.66, P=0.012) were associated with an increased risk of FNI. These results suggest that percutaneous approaches in the superficial group should be recommended for the treatment of CN/SCFs to reduce the risk of FNI.

Transmasseteric Anterior Parotid Approach for Treatment of Mandibular Subcondylar Fractures

This study demonstrated the application of transmasseteric anterior parotid approach for open reduction of mandibular subcondylar fractures depending on the basis of the anatomical study of the temporomandibular joint and parotid gland area. The anatomical study was performed on 5 Chinese adult cadavers fixed by 10% formalin. The temporomandibular joints and parotid regions were studied. In the clinical study, 26 patients with mandibular subcondylar fractures were recruited between July 2014 and December 2017. All 26 patients with mandibular subcondylar fractures received satisfactory occlusions and normal mouth opening: no postoperative facial paralysis occurred in these patients. It is crucial to know the anatomy of both temporomandibular joint and parotid region for reducing significantly the surgical trauma and complications. Transmasseteric anterior parotid approach is a feasible approach for the surgical treatment of the mandibular subcondylar fractures. This method can provide adequate exposure, minimal facial nerve injury, open reduction easily, and inconspicuous scarring.

Is the Retromandibular Transparotid Approach a Reliable Option for the Surgical Treatment of Condylar Fractures?

PURPOSE

This study evaluated the outcomes and complications of the surgical treatment of condylar fractures by the retromandibular transparotid approach. The authors hypothesized that such an approach would be safe and reliable for the treatment of most condylar fractures.

MATERIALS AND METHODS

A retrospective evaluation of patients who underwent surgical reduction of a condylar fracture from January 2012 to December 2014 at the Clinic of Dentistry and Maxillofacial Surgery of the University Hospital of Verona (Verona, Italy) was performed. Inclusion criteria were having undergone surgical treatment of condylar fractures with a retromandibular transparotid approach and the availability of computed tomograms of the preoperative and postoperative facial skeleton with a minimum follow-up of 1 year. Static and dynamic occlusal function, temporomandibular joint health status, presence of neurologic impairments, and esthetic outcomes were evaluated in all patients.

RESULTS

The sample was composed of 25 patients. Preinjury occlusion and temporomandibular joint health were restored in most patients. Esthetic outcomes were deemed satisfactory by clinicians and patients. Neither permanent neurologic impairments nor major postoperative complications were observed.

CONCLUSIONS

According to the results of the present study, the retromandibular transparotid approach is a viable and safe approach for the surgical treatment of condylar fractures.

Use of a modified high submandibular approach to treat condylar base fractures: Experience with 44 consecutive cases treated in a single institution

PURPOSE

The aim of this article is to present our experience treating fractures of the condylar base with a modification of the high submandibular approach (HSA).

MATERIALS AND METHODS

Between June 2012 and April 2015, 44 fractures of the condylar base were treated in the Department of Oral and Maxillofacial Surgery of the Medical Hospital of Graz using the modified HSA.

RESULTS

We did not observe any damage (even transient) to the facial nerve or any complication related to violation of the parotid capsule (such as a salivary fistula, Frey syndrome, or a sialocele).

CONCLUSIONS

This approach provides good access to the condylar base, ensuring easier internal fixation, excellent protection of the facial nerve and parotid gland, and good cosmetic results.