Mandibular condyle fractures: determinants of treatment and outcome

Personalized Temporomandibular Joint Total Alloplastic Replacement as a Solution to Help Patients with Non-Osteosynthesizable Comminuted Mandibular Head Fractures

Background: Treatment methods for mandibular head fractures are controversial, although effective techniques for open reduction and rigid fixation (ORIF) have been known since the late 1990s. Notably, some forms of posttraumatic comminution of the mandibular head can be reduced or fixed. Methods: This study presents a personalized treatment to cure patients with nonreduced comminuted fractures of the mandibular head: total temporomandibular joint alloplastic replacement (18 patients). The reference group included patients who underwent ORIF (11 patients). Results: Personalized alloplastic joint replacements resulted in a more stable mandibular ramus after three months compared with ORIF. Conclusions: The authors recommend not performing osteosynthesis when the height of the mandibular ramus cannot be stably restored or when periosteal elevation from most of the mandibular head is necessary for ORIF. Personalized TMJ replacement should be considered in such patients. Personalized medicine allows patients to maintain a normal mandibular ramus height for a long period of time.

Anatomical position of the mandibular condyle after open versus closed treatment of unilateral fractures: A three-dimensional analysis

This study aimed to compare open and closed treatment for unilateral mandibular condyle neck and base fractures by final three-dimensional (3D) condylar position at 6 months follow-up. 3D position was associated with mandibular functioning and pain. A total of 21 patients received open (n = 11) or closed (n = 10) treatment. 3D positions were assessed on cone-beam computed tomography scans. Volume differences, root mean square, translations, and rotations were obtained related to the pursued anatomical position and compared between treatment groups by the Mann-Whitney U test. The 3D position parameters were associated with the maximum interincisal opening (MIO), mixing ability test (MAT), Mandibular Function Impairment Questionnaire (MFIQ), and pain based on Spearman correlation coefficients (rs). Translation in the medial-lateral direction was smaller after open treatment (P = 0.014). 3D position was not associated with the MAT; however, worse position was associated with a smaller MIO. A larger pitch rotation was associated with a worse MFIQ (rs = 0.499, P = 0.025). Volume reduction of the affected condyle was associated with more pain (rs = -0.503, P = 0.020). In conclusion, after unilateral condylar fractures, worse 3D position is associated with a smaller mouth opening and worse patient-reported outcomes. This is independent of the chosen treatment, despite a better anatomical reduction after open treatment.

Treatment for Adult Mandibular Condylar Process Fractures: A Network Meta-Analysis of Randomized Clinical Trials

PURPOSE

Using network meta-analyses (NMA) has become increasingly valuable as it enables the comparison of interventions that have not been directly compared in a clinical trial. To date, there has not been a NMA of randomized clinical trials (RCT) that compares all types of treatments for mandibular condylar process fractures (MCPFs). The aim of this NMA was to compare and rank all the available methods used in the treatment of MCPFs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted in 3 major databases up to January 2023 to retrieve RCTs that compared various closed and open treatment methods for MCPFs. The predictor variable is treatment techniques: arch bars (ABs) + wire maxillomandibular fixation (MMF), rigid MMF with intermaxillary fixation screws, AB + functional therapy with elastic guidance (AB functional treatment), AB rigid MMF/functional treatment, single miniplate, double miniplate, lambda miniplate, rhomboid plate, and trapezoidal miniplate. Postoperative complications were the outcome variables and included occlusion, mobility, and pain, among other things. Risk ratio (RR) and standardized mean difference were calculated. Version 2 of the Cochrane risk-of-bias tool and Grading of Recommendations, Assessment, Development, and Evaluations system were used to determine the certainty of the results.

RESULTS

The NMA included a total of 10,259 patients from 29 RCTs. At ≤6 months, the NMA revealed that the use of 2-miniplates significantly reduced malocclusion compared to rigid MMF (RR = 2.93; confidence interval [CI]: 1.79 to 4.81; very low quality) and functional treatment (RR = 2.36; CI: 1.07 to 5.23; low quality).Further, at ≥6 months, 2-miniplates resulted in significantly lower malocclusion compared to rigid MMF with functional treatment (RR = 3.67; CI: 1.93 to 6.99; very low quality).Trapezoidal plate and AB functional treatment were ranked as the best options in 3-dimensional (3D) plates and closed groups, respectively.3D-miniplates (very low-quality evidence) were ranked as the most effective treatment for reducing postoperative malocclusion and improving mandibular functions after MCPFs, followed closely by double miniplates (moderate quality evidence).

CONCLUSIONS

This NMA found no substantial difference in functional outcomes between using 2-miniplates versus 3D-miniplates to treat MCPFs (low evidence).However, 2-miniplates led to better outcomes than closed treatment (moderate evidence).Additionally, 3D-miniplates produced better outcomes for lateral excursions, protrusive movements, and occlusion than closed treatment at ≤6 months (very low evidence).

Analysis of Mandibular Muscle Variations Following Condylar Fractures: A Systematic Review

This review analyzes muscle activity following mandibular condylar fracture (CF), with a focus on understanding the changes in masticatory muscles and temporomandibular joint (TMJ) functioning.

MATERIALS AND METHODS

The review was conducted following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. A search was performed on online databases using the keywords "masticatory muscles" AND ("mandibular fracture" OR "condylar fracture"). The eligibility criteria included clinical trials involving human intervention and focusing on muscle activity following a condylar fracture.

RESULTS

A total of 13 relevant studies were reviewed. Various studies evaluated muscle activity using clinical evaluation, bite force measurement, electromyography (EMG), magnetic sensors and radiological examinations to assess the impact of mandibular fractures on masticatory muscles.

CONCLUSIONS

Mandibular condylar fractures can lead to significant changes in muscle activity, affecting mastication and TMJ functioning. EMG and computed tomography (CT) imaging play crucial roles in assessing muscle changes and adaptations following fractures, providing valuable information for treatment planning and post-fracture management. Further research is required to explore long-term outcomes and functional performance after oral motor rehabilitation in patients with facial fractures. Standardized classifications and treatment approaches may help improve the comparability of future studies in this field.

Comparative evaluation of post treatment CT scan and clinical parameters in open reduction and closed reduction treatment of condylar fractures

Background

Mandibular fracture is the second most common fracture of facial bone, next to nasal bone. Twenty-five to forty percent of mandibular fractures involve the condyle. In the literature, there exists no consensus "gold standard" treatment for mandibular condylar fractures, and there is a continuing debate on whether condylar fractures should undergo closed or open reduction.

Materials and Method

Twenty patients who had undergone open reduction and closed reduction treatment were included in the study. Clinically maximal interincisal opening, laterotrusive and protrusive movements, pain on mouth opening, malocclusion, chin deviation on mouth opening, facial nerve palsy, hematoma, infected implant, and bite force were evaluated after a minimum of 3 months postoperatively. Also, a postoperative CT is done to evaluate the anatomical position of fragment.

Results

On evaluation of clinical parameters, both groups had comparable results. However, none of the patients in open reduction group had deviation of mandible from midline on mouth opening. Also, better anatomical repositioning is obtained in open reduction group.

Conclusion

The results of this study suggest that the open reduction method is a better alternative to closed reduction in treatment of mandibular condylar fractures.

Does the Treatment Approach for Mandibular Condyle Fractures Impact Self-Perceived Quality of Life?

PURPOSE

There is no consensus in mandibular condylar fracture/s treatment. In medicine, quality of life (QOL) includes the individual's satisfaction toward their own health condition, disease, or treatment. The purpose of this study was to investigate self-perception QOL outcomes for patients who sustained mandibular condylar fracture/s.

METHODS

This cross-sectional study surveyed patients at Grady Memorial Hospital in Atlanta, Georgia from November 2016 to June 2020. The study included patients who were at least 16 years old at the time of injury, diagnosed with mandibular condylar fracture/s, treated by close reduction or open reduction and internal fixation (ORIF), presented for 6-months post-operative follow-up, and had a valid phone number. The primary predictor variable was treatment approach. The primary outcome variable was mood. Covariates were demographics, injury details, and self-perception QOL questionnaire. Univariate, bivariate, and ordinal regression analysis were performed (P < .05 significance).

RESULTS

A total of 108 patients met inclusion criteria. Response rate was 84.2%. Our data showed that patients who underwent ORIF treatment were statistically more likely to experience no or milder pain when chewing (tau = 0.390, P = .002), to not require pain medications (tau = 0.389, P = .002), to report larger maximum mouth opening (tau = 0.402, P = .0003), and to report better QOL (tau = 0.440, P = 7.407e-05). Ordinal regression analysis showed that patients who had undergone ORIF treatment were positively associated with better mood (estimate: -0.062; OR: 0.54; P = .29) and statistically significant associated with excellent QOL (estimate: -2; OR: 0.13; P = 3.99e-05). Patients who sustained class III Lindahl mandibular condyle fracture were statistically significantly associated with depressed mood (estimate: 1.46; OR: 4.33; P = .002).

CONCLUSION

ORIF treatment was positively associated with better QOL when compared to closed reduction for mandibular condyle fracture.

Preauricular anteroparotid transmasseteric approach of the mandibular condyle: The natural evolution after cervical dissections? An anatomical feasibility study

The purpose of this study was to evaluate the reliability and reproducibility of a novel approach for base and neck fractures of the mandible. An anatomical study was conducted on 22 given to Science subjects. A rhytidectomy-like approach was performed, followed by a transmasseteric anteroparotid dissection. Measures were taken of the incision length and bone exposure at every step. The identification of a ramus of the facial nerve during dissection was noted. The subjects were classified according to their facial adiposity. A correlation coefficient was measured between incision length and bone exposure as well as morphotype and bone exposure. Statistical analysis was carried out using the Pearson method for linear correlation, and Chi2 test for further analysis. Adequate condylar exposure was always achieved in the area of interest (i.e. in the main localization of base and neck fractures). There was no correlation between the length of the cranial cutaneous backcut and the bone exposure horizontally (p = 0.3296) or vertically (p = 0.8382). There was no correlation between the total length of the incision and the bone exposure horizontally (p = 0.5171) or vertically (p = 0.8404). There was a significant correlation between the subjects' facial adiposity and the bone exposure horizontally and vertically (p&lt;0.005). This approach allowed adequate bone exposure to the mandible base and neck, with a possible 90° angulation of instruments for optimal bone fixation. The incidence of facial nerve rami identification during dissection was similar to other approaches. The scarring was hidden. These results allowed us to propose this approach in a clinical study.

The Osteosynthesis of the Mandibular Head, Does the Way the Screws Are Positioned Matter?

Currently, an increasing number of medical centers are treating mandibular head fractures surgically. Dedicated screws for compression osteosynthesis have been developed. However, due to the very limited size of the fractured bones and the considerable technical difficulties accompanying the execution of the fixation, there is little room for correction of the positioning and reinsertion of the screws. Therefore, knowing the optimal position of the fixation material is crucial for therapeutic success. The aim of this study is the evaluation of fixation screw position on the mandibular ramus height obtained in the treatment of the condylar head fracture. A total of 57 patients were included in this study. The loss of mandibular ramus height on computed tomography twelve months after mandibular head osteosynthesis was evaluated in relation to the initial distance of the screws from the fracture line, the angle of insertion of the screw into the bone, and the size of the protrusion to the inner side of the condyle. The relationship of the proximity of the screw to the fracture line, angulation, and the size of the protrusion with the loss of ramus height was confirmed. Conclusions: the optimal location for the superior screw is approx. 4 mm below the fracture line (with any angulation), inferior screw is approx. 8 mm (with any angulation), and anterior screw position is approx. 4-5 mm distant from fracture line with the best angulation of 130 degrees to the lateral mandible ramus surface in the coronal plane.

Bone Union Quality after Fracture Fixation of Mandibular Head with Compression Magnesium Screws

For some years now, fixation devices created with resorbable magnesium alloys for the mandibular head have been clinically available and are beginning to be used. It is thus valuable to evaluate the quality of unions in these cases. The aim of this study was radiological comparison of magnesium versus titanium open reduction and rigid fixations in the mandible condylar head. Thirty-one patients were treated for fractures of the mandibular head with magnesium WE43 alloy headless compression screws (diameter 2.3 mm) and, as a reference group, 29 patients were included with similar construction titanium screws (diameter 1.8 mm). The 12-month results of the treatment were evaluated by the texture analysis of CT. Near similar treatment results were found with magnesium screws in traditional titanium fixation. Magnesium screws result in a higher density of the bone structure in the mandibular head. Conclusions: The quantitative evaluation of bone union after surgical treatment of mandibular head fracture with magnesium compression headless screws indicates that stable consolidation was achieved. Undoubtedly, the resorption process of the screws was found to be incomplete after 12 months, evidenced by a marked densification of the bone structure at the fracture site.

A comparative evaluation of retromandibular versus Modified Risdon approach in surgical treatment of condylar fracture

The purpose of this study was aimed to compare the efficiency and safety of retromandibular versus modified Risdon approach using periangular incision for open reduction and internal fixation of low subcondylar mandibular fracture. Open reduction and internal fixation with different plating systems were utilized via retromandibular approach (group I) and via modified Risdon approach with periangular incision (group II). Twenty four (n= 24) condylar fractures in 21 adult patients were divided randomly into two equal groups (12 each) according to the cutaneous incision (approach) utilized. The evaluation score for scarring in group I it was excellent in 9 patients, good in 2 patients and acceptable in only one patient (Mean 2.4 ± SD 3.38). While in group II was excellent in 10 patients and good in 2 patients (Mean 2.4 ± SD 3.87) and the p value was 0.591. Symptoms of transient facial nerve weakness were noted in only 3 patients in group I with slight to moderate dysfunction (Mean 2 ± SD 3.21), while only one patient had facial nerve weakness in group II with House - Brackman score of 2 immediate postoperatively and this got resolved in 6 weeks (Mean 2 ± SD 4.04) and the p value was 0.00022. Within the limitations of the study it seems that a modified Risdon approach using periangular incision for reduction and fixation of low subcondylar fracture should be preferred whenever possible because it yields better outcomes.

"Does Mandibular Condylar Morphology After Fracture Healing Predict Functional Outcomes in Patients Treated With Closed Reduction?"

PURPOSE

The purpose of the study is to assess the healing temporomandibular joint morphology and function after closed treatment of unilateral mandibular condylar fracture.

MATERIALS AND METHODS

A prospective interventional cohort study was designed in patients recruited from the outpatient department who underwent closed reduction for unilateral condylar fractures, and mean mouth opening, mean maximum protrusion, laterotrusion, and radiological pattern of healing were noted.

RESULTS

Forty patients in the age group of 18-50 years (mean 24.5 years) were included. The difference between the pretreatment mean mouth opening (26.94 mm), mean maximum protrusion (1.22 mm), and laterotrusion (3.82 mm and 1.45 mm) values and the 6-month post-treatment values (46.3 mm, 4.45 mm, and 11.82 mm and 9.82 mm, respectively) was found to be statistically significant (P < .001). Deranged pretreatment occlusion seen in 20 cases was improved in 18 patients (85%) at the 6-month post-treatment visit, with persisting malocclusion in 2 patients (5%). Clinically, cases that had healed with the anatomical pattern (M1) were found to have significantly better clinical outcomes (P value < .05) than that achieved with cases healed with spherical pattern (M2), L-shaped pattern (M3), or detached pattern (M4). On radiographs, the greatest improvement (21.16 mm) in mean mouth opening values was seen in the M1 group (anatomical pattern), followed by similar improvement in groups M2 and M3 (18.39 and 18.66 mm, respectively). Least improvement (7.06 mm) was seen in the single case of the M4 group (detached pattern), although the 6-month post-treatment value was still an acceptable one (34 mm).

CONCLUSIONS

Favorable functional outcomes can be achieved after closed treatment, including adequate mouth opening, pain-free jaw excursions, and stable occlusion, with the anatomical healing pattern showing the most superior results and the detached pattern being associated with relatively poorer outcomes compared with other healing patterns.

The evaluation of alveolar fractures of trauma patients in Iran

BACKGROUND

Alveolar bone plays a vital role in mastication and supporting the teeth. The alveolar process is one of the most challenging regions of facial bone to reconstruct due to the deformity involves both hard and soft tissues. However, the etiology, gender, and age distribution vary between different regions, cultures, and countries. This study aims to investigate the prevalence of alveolar trauma in Shahid Rajaee Hospital, Shiraz, Iran, for three years.

METHODS

In a retrospective cross-sectional study, patients with alveolar fractures referred to Shahid Rajaei Hospital in Shiraz were included in the study. Age, sex, site of alveolar fractures, and etiology factors of trauma explored. The collected data was analyzed by SPSS software. Mean [Formula: see text] SD calculated for the inferential statistics, and the data compared using Chi-square and Exact Fisher. A p-value of < 0.05 was considered statistically significant with a 95% reliability.

RESULTS

A total of 165 patients had alveolar fractures in this study. We found that the most common cause of alveolar fracture was road accidents (32.3%) and the lowest reason was violence (9%). Most people with alveolar trauma were male and in the 21-30 years. The prevalence of mandibular and maxillary alveolar fractures was 17.61 and 17.01%, respectively, with the most anterior area of injury.

CONCLUSION

Alveolar trauma is one of the most common injuries among trauma patients. Early diagnosis and treatment plans are necessary to reduce the complications of facial trauma. Early training for a young adult is essential to prevent the severity of trauma.

Prediction of Conservative Treatment Failure for Isolated Unilateral Mandibular Condylar Fractures Using Quantitative Measures: Suggestion of Indications for Intervention

BACKGROUND

Interest in the treatment of mandibular condyle fracture in cases of maxillofacial trauma has been a huge concern for decades because of a diversity of opinions on the topic and the relatively few studies conducted on individuals treated by physiotherapy or rehabilitation with or without intermaxillary fixation (IMF).

METHODS

We measured fracture gaps between bone ends over an 8-year period from 2012 to 2019. The study cohort was composed of only conservatively treated patients. This retrospective study was conducted to identify factors that influence treatment failure by comparing a functional treatment (physiotherapy) group with an IMF group in terms of fracture gaps and other variables. In addition, an algorithm was devised to enable clinicians to determine promptly whether IMF is needed for mandibular condylar fractures.

RESULTS

Significant correlations were observed between several parameters and malocclusion. Multiple regression analysis resulted in the following coefficients: 0.072 for fracture gap (P = 0.006) and 0.006 for age (P < 0.05) in functional treatment group. However, in the IMF group, correlations with malocclusion were 0.063 for fracture gap (P = 0.000) and 0.003 for age (P = 0.083).

CONCLUSIONS

We proposed a diagnostic algorithm for isolated unilateral mandibular condyle fractures that provides guidance regarding surgical correction. If indications for surgical correction, as regards anatomical location, fracture level, fracture gap between bone ends, and patient cooperability, are not satisfied, clinicians should select IMF or functional treatment (rehabilitation). If the fracture gap is less than 6 mm and the patient is cooperative, functional rehabilitation would be more suitable than IMF.

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 magnitude of deformity correlate with functional outcome following closed reduction in unilateral condylar fracture?

Introduction: Condyle fracture can be treated surgically (ORIF) or conservatively (CTR). When treated by CTR, the fracture might not heal in a morphologically ideal shape. The severity of the deformity and its effects on the functional outcome is not known. This study would investigate the anatomical outcome of CTR and its effect on the functional outcome. Methods: Using a cross-sectional study design, we enrolled patients identified from our trauma census that meets the pre-determined inclusion criteria. Patient underwent assessment which involves clinical and radiographic evaluation. Clinical examination was done by using Helkimo Index. Radiographic evaluation by using cone beam computed tomography (CBCT) scan were traced and digitized, and the position and morphology of the fractured mandibular condyle was measured and compared with those of the contralateral non-fractured condyle in the axial, coronal and sagittal planes. Radiographic data was then compared with data from clinical examination. Results: 25 patients with unilateral condyle fracture and met the inclusion criteria were identified. Eight patients were successfully recalled and included in the study. Assessment was done on average of 40 months post-treatment. Clinical assessment with Helkimo Index showed that 63% had at least mild temporomandibular symptoms or dysfunction. CBCT examinations revealed that most patients had morphologically deformed healed condyle. No pattern can be seen in the magnitude of deformity with functional outcome. Conclusions: Following CTR, condyle fracture would heal in a morphologically deformed shape. Satisfactory functional outcome is still attainable despite this. The magnitude of the deformity does not appear to influence the functional outcome.

Analysis between Retromandibular and Periangular Transmasseteric Approach for Fixation of Condylar Fracture - A Prospective Study

Introduction:

Condylar fractures make up for an average of 17.5%–52% of all mandibular fractures. The aim of the present study was to compare the ease, success, and complications between retromandibular and periangular transmasseteric approaches when used for open reduction and internal fixation of condylar fractures.

Materials and Methods:

A total 20 cases with condylar fracture, ten each for retromandibular and periangular transmasseteric approach, were included in the study. Patients were evaluated at 1 week, 1 month, 3 months, and 6 months. Postoperative occlusion, maximum mouth opening, range of movement, facial nerve function, visibility, convenience of plating, and time taken for exposure, fixation, and closure were recorded. Incidence of complications such as wound dehiscence, wound infection, hematoma, sialocele formation, Frey's syndrome, and hypertrophic scars were also evaluated.

Results:

The mean exposure time in the retromandibular approach was 10 min 31 s and 9 min 17 s in the periangular transmasseteric approach. The incidence of facial nerve injury was 2 of 10 patients in the retromandibular group and 3 of 10 patients in the periangular transmasseteric group, all of which resolved within 6 months. The incidence of sialocoele was 2 of 10 in the retromandibular group. The time taken for exposure of the fracture site was statistically significant between the two approaches (P = 0.048) with longer time required for retromandibular approach.

Discussion:

It can be summarized that both the approaches are comparable and well suited for surgical management of condylar fractures. It was observed that in displaced condylar neck fractures, greater difficulty was experienced in the periangular transmasseteric approach than the retromandibular approach.

Comparative Evaluation of Clinical and Radiological Outcomes of Retromandibular Transparotid and Transoral Endoscopic-Assisted Approach for Surgical Management of Mandibular Subcondylar Fractures

Study Design

A prospective randomized comparative study was conducted to evaluate the clinical and radiological outcomes of the retromandibular transparotid (RMT) approach with endoscopic-assisted transoral (ENDO) approach used for open reduction and internal fixation (ORIF) of adult mandibular subcondylar fractures.

Objectives

To evaluate and compare the primary functional outcome using the Helkimo's dysfunction index, the surgical ease, the incidence of facial nerve weakness, the cosmetic outcomes and the number of complications following ORIF of mandibular subcodylar fractures using the RMT and ENDO approaches.

Methods

In this prospective study, 20 patients with unilateral/bilateral subcondylay fractures requiring ORIF were recruited between 2017 and 2018. Patients were randomly divided into RMT and ENDO group, 10 patients in each. Clinical and radiological assessment was done preoperatively and in postoperative period it was done at different intervals over the period of 6 months. The intraoperative parameter time taken during surgery was correlated for association with the time elasped since day of trauma and with the fracture severity. Similarly, the presence of multiple fractures of the mandible and postoperative occlusion were evaluated for the association.

Results

Comparable functional results were noted in both groups without any statistical significance. ORIF in ENDO group proved to be more time-consuming. For the RMT group, visible scars were rated best or close to best at the end of 6 months but a greater number of facial nerve injuries were reported in the RMT group.

Conclusions

Superiority of one approach over others cannot be established since the outcomes were not statistically different. However, the ENDO approach appears to be safer. Therefore, there is a need for the development of innovative armamentarium which would improve the dexterity and ease of the surgeon and hence the total time taken for this minimally invasive approach for the management of subcondylar fracture.

Open Treatment of Mandibular Condyle by Direct Transparotid Approach: Our Experience

The fractures of the mandibular condyle are commonly encountered in maxillofacial surgical practice. The controversies to open or not to open are still ongoing. We have used both techniques, to successfully manage our patients. Open treatment of condyle fracture with or without dislocation is technically challenging. We used a "Direct Transparotid" approach in treating 13 condyle fractures over a period of 4 years. The patients were evaluated for facial nerve injury, salivary fistula, scar, function, and occlusion over a period of 12 months. There were no major complications with acceptable scar, both intraoperatively and postoperatively. The script aims at presenting our experience of direct transparotid approach surgical technique.

Establishing a Protocol for Closed Treatment of Mandibular Condyle Fractures with Dynamic Elastic Therapy

Treatment of mandibular condyle fractures is controversial. Open treatment achieves anatomic reduction with occlusal stability and faster functional recovery but risks facial nerve injury and jeopardizes joint capsule circulation which can lead to bone resorption. Traditional closed treatment avoids these issues but requires prolonged fixation and risks subsequent facial asymmetry, occlusal disturbance, and ankylosis. Rather than wires, closed treatment with elastics allows for customizable management of a healing fracture with ability to alter vector and degree of traction to restore vertical height and occlusion with less discomfort and decreased risk for ankylosis. In this protocol, unilateral condylar fractures were treated with class II elastics ipsilateral to injury and class I contralaterally. Class III elastics were used contralaterally if additional traction was required and Class II elastics were placed bilaterally for bilateral fractures. Patients were sequentially advanced from fixating to guiding to supportive elastics by titrating elastic vector to any dental midline incongruency or chin deviation. Six patients were treated with this protocol with six-month follow-up. Fracture patterns included displaced and dislocated fractures as well as intracapsular and extracapsular condylar fractures. All patients at completion of the protocol had objective centric occlusion with no subjective malocclusion, chin deviation, facial asymmetry, or temporomandibular joint pain. These early data demonstrate a safe and efficacious innovative protocol for closed treatment of mandibular condylar fractures with dynamic elastic therapy.

Mechanical Evaluation of Titanium Plates for Osteoesynthesis High Neck Condylar Fracture of Mandible

Background: In the literature no information about plates for the high-neck mandibular condylar osteosynthesis could be found despite that 30 plate designs have been published. The main course consider the basal condylar or diacapitular fractures. The aim of the study was to test mechanically all available designs (only 4 of 30 was proper) on polyurethane mandibles using an individually designed clamping system. Methods: Forces required for a 1 mm displacement of fixed fracture fragments and incidents of screw loosening were recorded. Results: It has occured that dedicated plates for fixation are much weaker than set of two straight plates (p < 0.0001). General observation is the bigger plate and more screws, the better rigid stable osteosynthesis of mandibular condyle, however, there are limitations in plates design for high-neck fractures resulted in restricted operation field. Conclusion: Double straight plates occured to be the best mechanical fixation for high-neck fractures of the mandibular condyle. Maybe other existing plates could be used but only after prebending or that fracture required novel dedicated plates design.

Prognosis of diacapitular condylar fractures: a multivariate analysis

The choice of treatment for diacapitular condylar fractures remains in dispute among oral and maxillofacial surgeons. A multivariate retrospective study was designed to compare the prognosis after conservative treatment and surgery, and to explore further indications for management. From 1 July 2013 to 30 June 2017, 169 patients with diacapitular condylar fractures were included. Relevant preoperative data were collected, and the prognoses assessed. Three ordinal logistic regression models were constructed to study the factors that affected prognosis, and these showed that all patients treated by open reduction and internal fixation (ORIF) tended to have a better prognosis than those treated with conservative treatment (adult: odds ratio (OR)=6.166, p=0.000, and children: OR=12.195, p=0.029). Adult patients with lateral dislocation of the stump of the ramus out of the glenoid fossa tended to have the highest risk of a poor prognosis, followed by those with anteromedial displacement of the disc and loss of the height of the ramus of over 5mm. Only the type of treatment affected the prognosis for children. In conclusion, these findings suggest that ORIF is the preferred method of treatment for patients with diacapitular condylar fractures. The absolute indications for ORIF in adult patients with diacapitular condylar fractures include lateral dislocation of the stump of the ramus out of the glenoid fossa, anteromedial displacement of the disc, and loss of height of the ramus of over 5mm. There are no absolute indications for ORIF in children.

Biomechanical Evaluation of Mandibular Condyle Fracture Osteosynthesis Using the Rhombic Three-Dimensional Condylar Fracture Plate

PURPOSE

The aim of the present study was to evaluate the biomechanical stability of osteosynthesis in mandibular condyle fractures using a newly designed rhombic 3-dimensional (3D) condylar fracture plate and compare it with that using standard two 4-hole miniplates and with that in nonfractured condyles.

MATERIALS AND METHODS

Using 200 porcine mandibles, 3 different monocortical plating techniques were evaluated. The condyles were fractured along a defined line tangentially through the sigmoid notch and perpendicular to the posterior border. After anatomic reduction, osteosynthesis was performed using either standard rhombic 3D condylar fracture plates and standard screws (group A) or locking rhombic 3D condylar fracture plates, which were fixed either with standard screws (group B) or locking screws (group C). For comparison, nonfractured condyles (group D) and condyles fixed with standard two 4-hole miniplates and 8 screws (group E) were included. Using a universal mechanical testing machine (TIRA Test 2720; TIRA GmbH Schalkau, Germany), each group was subjected to linear loading from laterally to medially, medially to laterally, anteriorly to posteriorly, and posteriorly to anteriorly. The maximum axial force and displacement at the maximum force were measured. The mean values were compared for statistical significance using analysis of variance with Bonferroni's correction (statistical significance set at P < .05).

RESULTS

The main mode of failure in the plating techniques investigated was the pull out of screws from the proximal fragment. We found no statistically significant differences in the stability of osteosynthesis between the two 4-hole miniplates and the rhombic 3D condylar fracture plate when loading from posteriorly to anteriorly, laterally to medially, and medially to laterally. However, when loading from anteriorly to posteriorly, a statistically significant difference between the standard and locking system and the two 4-hole miniplate system was observed, with the latter proving more stable.

CONCLUSIONS

The results of the present biomechanical study suggest that the rhombic 3D condylar fracture plates are suitable for the treatment of condylar neck fractures. Both types of the plate are able to resist physiologic strains comparable to the two 4-hole miniplates.

A comparative study of intraoral versus retromandibular approach in the management of subcondylar fracture

Background

The purpose of this study was to compare the outcomes and effectiveness between intraoral approach and retromandibular approach for treatment of subcondylar fracture of mandible.

Methods

Between March 2011 and October 2013, 24 patients with subcondylar fractures of the mandible were treated by a single surgeon with an intraoral approach using an angulated screwdriver (n = 14) or by another surgeon using a retromandibular approach (n = 10). The interincisal distance was measured 1 week (T0), 6 weeks (T1), 3 months (T2), and 6 months (T3) postoperatively. We also compare the average operation time and the cost of operation between the two groups.

Results

At 6 months postoperatively, all 24 patients achieved satisfactory ranges of temporomandibular joint movement, with an interincisal distance > 40 mm without deviation and with stable centric occlusion. The intraoral group had the median interincisal distance of 14 mm at T0, 38 mm at T1, 42.5 mm at T2, and 43 mm at T3, while the retromandibular group had that of 15, 29, 35, and 42.5 mm respectively. There was no statistically significant difference between the intraoral and the retromandibular group at T0 and T4. However, significant differences were noted T1 and T2 (p < 0.01). The differences of average operation time between the intraoral (81 min) and retromandibular group (45 min) were statistically significant (p < 0.01). The cost of an operation was 369.96 ± 8.14 (United States dollar [USD]) in intraoral group and was 345.48 ± 0.0 (USD) in retromandibular group. The differences between the two groups were statistically significant (p < 0.01).

Conclusion

In open reduction of a subcondylar fracture of the mandible, a intraoral approach using an angulated screwdriver is superior to the retromandibular approach in terms of interincisal distance, although the operation time is longer.

Does Intraoperative Navigation Improve the Anatomical Reduction of Intracapsular Condylar Fractures?

PURPOSE

Accurate reduction of intracapsular condylar fractures is the key to successful reconstruction of the temporomandibular joint and remains a challenge for oral and maxillofacial surgeons. The aim of the study was to evaluate quantitatively the effect of surgical navigation on the accuracy of reduction of intracapsular fractures.

MATERIALS AND METHODS

In this prospective randomized nonblinded controlled clinical trial, patients diagnosed with intracapsular condylar fractures who were scheduled for surgical treatment were included and randomized to open treatment with or without surgical navigation. The primary predictor variable was surgical navigation. The primary outcome variable was the average distance (AD) between preoperative and postoperative computed tomographic measurements. The second outcome variable was the rate of anatomic reduction. The χ² test and independent-samples t test were used for statistical analyses.

RESULTS

Twenty patients (33 sides) with intracapsular condylar fractures were enrolled and treated with open surgery (13 male, 7 female; mean age, 28.65 yr; range, 13 to 54 yr). Of these, 10 patients (16 sides) and 10 patients (17 sides) were treated, respectively, with and without surgical navigation technology. All patients underwent follow-up at 1, 3, 6, and 12 months. The mean AD was 0.5235 mm in the navigation group and 1.170 mm in the control group (P < .001). The rate of anatomic reduction was 93.8% in the navigation group and 88.2% in the control group (P = .58). The results indicated that a more precise reduction was achieved in the navigation group than in the control group.

CONCLUSION

According to the study results, the rate of anatomic reduction increased and the ADs decreased in the navigation group compared with the control group. Therefore, surgical navigation could increase the accuracy of reduction during the surgical treatment of intracapsular condylar fractures.

Surgical Treatment for Extracapsular Condylar Fractures of the Mandible

BACKGROUND

Condylar fractures are considered the most controversial mandibular fractures, regarding both the diagnosis and the treatment. With the increase in surgical indications for handling this type of fracture, it is important to discuss about the advantages and disadvantages of the several surgical approaches available. This article describes the surgical details and postoperative results of the mini-retromandibular transparotid approach for treating extracapsular condylar fractures of the mandible.

METHODS

In a 1-year period, 16 patients affected by extracapsular condylar fractures with surgical indication were treated with the mini-retromandibular transparotid approach. All the surgeries were executed by the same surgeon. Preoperative and postoperative details of each patient were analyzed.

RESULTS

In the postoperatory, only 2 patients had purulent drainage in the associated fractures area and only 1 patient had paresis of the buccal branch of the facial nerve. No scar issues concerning the surgical wound were observed and reintervention was not necessary in any of the patients.

CONCLUSION

The mini-retromandibular transparotid approach offers advantages and should be included as an option for the open treatment of extracapsular condylar fractures of the mandible.

Non-surgical Treatment of Condylar Fracture in an 11-Year-Old Patient: a Case Report

Background

Mandibular condylar fractures commonly occur after trauma and account for 25 to 35% of all mandibular fractures; its appropriate therapy still remains a point of controversy in children. The purpose of this paper is to describe the treatment of an 11-years-old male patient affected by neck-condylar fracture as result of trauma in evolutive age.

Methods

No surgical treatment was performed. A functional therapy was applied with a jaw splint. A closed treatment for mandibular condyle fractures was preferred because the amount of condylar displacement wasn’t considerable.

Results

The early treatment with functional therapy generated a functional adaptation of the condyle in the glenoid fossa and a normal mandibular function. After a 12-month follow-up the fracture resolution and an optimal condylar position were recorded.

Conclusions

The current case report and literature review showed that non-surgical therapy of neck-condylar fracture in a child with lower resin splint can restore mandibular movements and aesthetics. Facial growth after one year treatment resulted normal. A conservative treatment may be appropriate for children in selected cases with minimally displaced condyle.

Experiences with a modified preauricular mini incision with subdermally dissection in condylar and subcondylar fractures of the mandible

OBJECTIVE

Condylar and subcondylar fractures (CSFs) are among the most common mandible fractures. If reduction of these fractures is not carried out correctly, serious complications can result, including infection, damage to temporomandibular joint (TMJ) function, malocclusion, nonunion, malunion, and ankylosis of the TMJ.

METHODS

We used a preauricular, mini-incision, open technique (PMIOT) for CSF of the mandible. 66 patients (48 males, 18 females), with a total of 72 CSFs of the mandible, were repaired with PMIOT between 2011 and 2016. Average age was 37.8 years (range: 8-78). CSFs were located on the right side, left side, and bilaterally in 21, 27 and six patients, respectively. We used only one mini incision of length 2 cm for non-displaced subcondylar fractures. However, we had to perform a second mini incision for condylar fractures displaced by more than 45°, where subcondylar fractures overlapped, or where there was deep surgical exposure and difficulty with reduction.

RESULTS

No early complications, such as bleeding, hematoma, seroma, infection, or parotid fistula, were seen in any patients. Temporary facial nerve paresis was reported in three patients, but these recovered spontaneously with conservative treatment within 15 days. Permanent facial nerve paralysis occurred in none of the patients.

CONCLUSION

We believe that PMIOT is an effective, reliable, and feasible method for repair of CSF. It does not need any expensive and sophisticated tools, and has low complication rates. The mini incision used in our technique results in both a hidden scar and protection of essential structures in the region.

A Modified External Fixator System in Treatment of Mandibular Condylar Fractures

The purpose of this study is to evaluate patient's outcomes after condylar fractures treated with the modified external fixation system from 2008 to 2012.A group of 58 patients with unilateral and bilateral fractures of mandibular condyle was admitted in the authors' study.The final sample included a total of 44 patients, 24 males (54.6%) and 20 females (45.4%).The remaining 14 (24%) patients were excluded because they did not fulfill all the criteria requested.After 12 months from surgery, the functional-clinical evaluation of mouth's maximum opening and mostly extent of lateral excursion and of protrusion showed the following results: 8% of the sample showed a maximum mouth opening <30 mm, 72% of the sample showed a maximum mouth opening between 30 and 40 mm, 20% of the sample showed a maximum mouth opening >40 mm lateral excursion (contralateral to fracture) and protrusion was respectively of 9.5 and 3.9 mm.Only 2 (4.5%) of the 44 evaluated patients reported headaches. 86.5% of the patients showed no postoperative temporomandibular joint dysfunction; 9% of them reported occasional clicking, while 4.5% reported recurrent disorders. The average satisfaction score of surgery outcome reported by patients was 94.5/100, and it ranged between 50/100 and 100/100.

Condylar Fractures: Review of 40 Cases

Purpose:

To put an algorithmic approach for the treatment of condylar fractures according to the condition of occlusion.

Patients and Methods:

This study had been carried out between May 2016 and April 2017. Forty patients were included (6 females and 34 males) with their ages ranged between 3 and 60 years. Patients were managed through two approaches as follows: maxillomandibular fixation (MMF) only regimen and MMF with open reduction and internal fixation regimen. The operated cases were 12 with bilateral condylar/subcondylar fractures, and the rest were unilateral 28 cases.

Results:

Data were assessed demographically, time lapse before the intervention, surgically, functionally, and radiologically. In general, there were no significant differences between closed and open methods.

Conclusion:

Retromandibular approach was convenient for internal fixation of condylar fracture with a good outcome. In our work, there were no significant differences between closed and open methods in the treatment of condylar fractures.

In-vitro comparison of mechanical resistance between two straight plates and a Y-plate for fixation of mandibular condyle fractures

OBJECTIVE

To compare the mechanical resistance of conventional plates with a modified Y-plate in mandibular condyle fracture.

MATERIALS AND METHODS

40 synthetic hemi-mandibular polyurethane replicates were used. Two groups of fixing materials were included: 20 mandibles fixed with 40 straight plates with four roles each (2.0 mm system) and 20 mandibles fixed with 20 Y-shaped plates (2.0 mm system and 1.5 mm thickness). The samples were submitted to linear loading in the following directions: 10 mandibles from each group from lateral to medial and 10 mandibles from each group from anterior to posterior. A universal loading machine, Instron Universal 4411, was used to performed the tests, and the resistance of each fixed mandible was assessed at displacements of 1 mm, 3 mm, and 5 mm. The t-test for independent samples was performed. The p value was set at <0.05.

RESULTS

The worst mechanical resistance was found in the Y-plates loaded from anterior to posterior. The best mechanical resistance was in two straight hole plates loaded from lateral to medial. The Y-plates and two straight hole plates showed similar resistance when a lateral to medial load was applied.

CONCLUSION

There was no difference between the plates when lateral to medial loading was tested.

Retromandibular reduction of medially dislocated condylar process fractures

Background

Condylar process fractures account for one-third of all mandibular fractures, and the distal fragment is prone to dislocate to the medial side due to the pulling of the lateral pterygoid muscle. Retromandibular approaches are commonly used, but the intraoperative view becomes limited in medially dislocated fractures. This study summarized a series of cases of retromandibular reduction for medially dislocated condylar process fractures and described our supplementary procedure to realign the dislocated condylar process.

Methods

Nine patients with medially dislocated condylar process fractures underwent surgical correction from January 2012 to December 2016. In 6 of them, it was possible to realign the fractures with a conventional retromandibular approach, but for 3 cases of severe dislocation to the middle cranial fossa, a supplementary transoral procedure was carried out. The angle difference between the ramus and condyle, ramus height, and maximal mouth opening (MMO) were evaluated.

Results

All 9 cases were restored to the proper anatomical alignment without any major complications, and postoperative images revealed successful union. The angle difference was 8.94°±4.11° preoperatively, and 0.99±0.49° at the 6-month follow-up. The pretreatment ramus height difference was 6.12±6.09 mm, and the postoperative difference was 0.18±0.10 mm. These changes after surgery were statistically significant. The MMO before surgery was 11.44±3.0 mm, and the postoperative MMO was 37.2±2.9 mm, reflecting a significant increase after reduction.

Conclusions

Retromandibular reduction is a useful method in medially dislocated condylar process fractures, and additional transoral assistance should be considered to realign condylar processes that severely dislocate to the middle cranial fossa.

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.

Mandibular angle fractures: a comparative study between one- and two-plate fixation

BACKGROUND/AIM

The mandibular angle fracture is a challenging fracture to manage. Over time, the literature has shown many types of treatment modalities and different kinds of internal fixation. The aim of this study was to evaluate the outcomes and complications of mandibular angle fractures managed by Champy's technique and two-plate fixation, over a period of 20 years.

MATERIAL AND METHODS

The files of 149 patients with 155 angle fractures fulfilled the inclusion criteria and were chosen for this study. Data were collected regarding gender, age, race, date of trauma, addictions, etiology, signs and symptoms, fracture management, and complications.

RESULTS

Prevalence was higher in males (82%), Caucasians (62%), and during the third decade of life (62%). Mean age was 26.5 years. The main cause was interpersonal violence, and the mean follow-up period was 232 days. The main signs and symptoms were pain, edema, and mouth-opening restriction. The most often associated fracture involved the mandibular condyle, and the most common complication was infection.

CONCLUSION

There was no difference between the two modalities of treatment. However, the one-plate fixation technique had fewer complications.

Controversies in the Management of the Trauma Patient

Facial trauma is a significant cause of morbidity in the United States. Despite the large volume of trauma surgeries at most academic institutions, there is still controversy regarding management of many traumatic injuries. The literature lacks clear-cut best practices for most fractures. In orbital trauma, there is debate about the optimal timing of repair, preferred biomaterial to be used, and the utility of evaluation afterward with intraoperative computed tomographic scan. In repair of mandible fractures, there is debate regarding open versus closed reduction of subcondylar fractures, or alternatively, endoscopic repair.

Characteristics of temporomandibular joint structures after mandibular condyle fractures revealed by magnetic resonance imaging

Background

This study aimed to evaluate the structural changes of temporomandibular joint immediately after condylar fractures with magnetic resonance imaging (MRI).

Method

We evaluated 34 subjects of condylar fractures with MRI. The position, shape, and signal intensity of the condyle, disc, and retrodiscal tissue were analyzed with MR images.

Results

Immediately after trauma, the disc was displaced with the fractured segment in almost all cases. And, the changes of signal intensity at the retrodiscal tissue were found but less related to the degree of fracture displacement. And, the high signals were observed almost at all fractured joint spaces and even at some contralateral joints.

Conclusions

The displaced disc as well as the increased signal intensity of the joint space, condylar head, and retrodiscal tissue demands more attention to prevent the possible sequela of joint.

Comparison of Different Fixation Types Used in Unilateral Mandibular Condylar Fractures: An In Vivo Study With New Biomechanical Model

INTRODUCTION

The aim of this in vivo study is to compare the single-titanium, double-titanium mini plate, and single resorbable plate systems used in internal rigid fixation of the unilateral mandibular condylar fractures on new design biomechanical model.

METHODS

Thirty synthetic polyurethane models were used for biomechanical testing. Fracture lines were created for each model. Fragments were fixed with single-titanium plates in Group A (n = 10), double-titanium plates in Group B (n = 10), and single biodegradable plate (PPLA) in Group C (n = 10). Masticatory forces were applied to the models and the biomechanical properties of the titanium plate and screws, resorbable plate, and screws were evaluated.

RESULTS

The average failure force for Group A, Group B, and Group C is 199, 324, 177N and the average bone displacement for Group A, Group B, Group C is 1.9, 0.3, 2.1 mm, respectively.

DISCUSSION

Double titanium plates showed the most acceptable results in the fixation of unilateral subcondylar fractures where the single titanium and biodegradable plate systems failed to provide enough stability in unilateral subcondylar fracture fixation. Biodegradable plate systems are still not an alternative in fixation of unilateral condylar fractures.

Remodeling of Displaced Condylar Fractures with Functional Treatment: High-Quality Radiographic Documentation in Three-Patient Series

Treatment of condylar fractures is variable and controversial. Treatment options for management of condylar fractures include surgical and nonsurgical methods, and if a nonsurgical method is as effective as a surgical method, the former is preferred. Although plain film radiographs and functional outcomes attained through nonsurgical treatment are well established in literature, evidence of the remodeling process through detailed, high-quality imaging is lacking. The purpose of this case series is to describe and illustrate two adults and one pediatric patient with significantly displaced condylar fractures treated nonsurgically with excellent clinical results. It is unique for such patients to have pre- and posttreatment computed tomography scans with high-quality three-dimensional reconstruction as in the case of two adults and to have 3.5-year posttrauma radiographs and 14.5-year follow-up as in the case of the pediatric patient. As such, this report is useful in visually presenting three examples of repositioning and reformation of the temporomandibular joint structures in displaced condylar fractures in a postmenarche 14-year-old female patient, a 21-year-old male patient, and an 18-month-old male patient.