A Modified Peri-Angular Approach for Exposure of Condylar Fractures

Postoperative Complications following Open Reduction and Rigid Internal Fixation of Mandibular Condylar Fracture Using the High Perimandibular Approach

The high perimandibular approach is a feasible surgical technique for treating mandibular condylar fractures with open reduction and internal fixation, followed by fewer complications. Temporary trismus is the only postoperative complication that may occur. This study evaluated postoperative complications following open reduction and rigid internal fixation (OR-IF) of mandibular condylar fractures using the high perimandibular approach. Twenty consecutive patients undergoing OR-IF were included in this study. They included 11 male and 9 female patients, of an average age of 58.5 years, all of whom responded to a follow-up call at least 12 months after the surgery. All patients were evaluated for range of mouth opening, postoperative complications, and radiological findings. A statistical analysis of the relationship between range of mouth opening and related clinical parameters at 6 months postoperative evaluation was conducted. The fracture of the condylar neck was associated with a limited range of mouth opening and longer operation time. However, longer operation time was not associated with a limited range of mouth opening. The high perimandibular approach with OR-IF in mandibular condylar fractures is a feasible and safe technique; however, prolonged surgery and mandibular condylar neck fractures could affect the postoperative range of mouth opening.

Infinitesimal Periangular Pterygomasseteric Transectioning Approach for the Base Fractures of the Mandibular Condyle: A Technical Note and Quality of Life Outcome

Purpose Infinitesimal Periangular Pterygomasseteric Transectioning Approach (IPPTA) is a minimal access surgical approach utilized for the management of base fractures of the mandibular condyle. The aim of the study was to evaluate and report the long-term post-operative functional outcome using this surgical access approach. Materials and method A prospective clinical study involving 20 patients was undertaken to evaluate the post-operative functional and aesthetic outcome for the patients that underwent surgery for base fractures of the mandibular condyle using IPPTA. The various parameters assessed were wound healing, marginal mandibular nerve injury, diet intake, mandibular function, and any other complications at twelfth post-operative month. Results IPPTA provided adequate exposure to the condylar base fracture for open reduction and internal fixation (ORIF) and was found to have an uneventful post-operative recovery phase in terms of functional and aesthetic outcomes. Conclusion IPPTA involves utilizing a smaller incision and provides adequate exposure to the condylar base region for ORIF to establish a satisfactory form and function with a predictable outcome.

Analysis of the High Submandibular Approach: A Critical Reapprasail of a Transfacial Access to the Mandibular Skeleton

AIM

In 2006 following the development of dedicated osteosynthesis plates, Meyer and colleagues reported a successful clinical study of condylar fractures treated by a modified submandibular approach; it was called high submandibular approach or "Strasbourg approach." The aim of this study is to describe the high submandibular approach step by step.

CASE SERIES

Between January 2010 and December 2015 at the Maxillofacial Unit of the Hospital "Policlinico San Martino" 13 patients affected by subcondylar fracture underwent open reduction and internal with high submandibular approach. Surgery was uneventful in all patients; no infections occurred in any of the cases; the mean procedure duration was 89 minutes, ranging from 66 to 125 minutes. The mean hospital stay was 2.9 days, ranging from 2 to 6 days. At the 1-year follow-up, all patients had stable occlusion with a natural, well-balanced morphology of the face and adequate dynamic excursion of the mandible.

CONCLUSIONS

The morbidity is negligible in terms of damage to the facial nerve, vascular injuries, and aesthetic deformity. The authors think that further prospective clinical trials are necessary to assess and eventually develop this approach.

Infinitesimal Peri-angular Pterygomasseteric Transectioning Approach (IPPTA) for the Base Fractures of the Mandibular Condyle: A Preliminary Study

Purpose

To investigate a reliable and safe surgical access to the condylar base region with minimal surgical trauma to the surrounding anatomic structures. In an attempt to do so, to describe Infinitesimal Peri-angular Pterygomasseteric Transectioning Approach (IPPTA) for the management of base fractures of the mandibular condyle.

Materials and Method

A preliminary clinical study involving 20 patients was undertaken to treat patients with unilateral condylar base fracture of the mandible using IPPTA under general anaesthesia (GA). Various parameters assessed were adequacy of surgical access, wound healing at the incision site, marginal mandibular nerve injury, diet intake and complications post-operatively.

Result

This method provided adequate exposure to fractured condylar base for open reduction and internal fixation (ORIF) with uneventful post-operative recovery phase. There was no limitation to function which was identified by restoration of normal pre-trauma diet intake by 14th post-operative day in more than 50% of the study patients. No complications were observed in any patients among the study population.

Discussion

The peri-angular approach has been discussed in the literature. The IPPTA highlights the use of a smaller incision providing an adequate exposure to the condylar base region for ORIF.

Evaluation of Open Reduction and Internal Fixation of Mandibular Condyle Fracture by Intraoperative Cone-Beam Computed Tomography in a Hybrid Operating Room

Condylar fractures are the most common fractures of the mandible, and treatment of mandibular condylar fractures by maxillofacial surgeons is a very important procedure. However, the surgical approaches have anatomical limitations. Therefore, it is difficult to evaluate the reduction achieved in open reduction and internal fixation because of the uncertainty in securing a sufficient operative field. As a potential solution, the authors evaluated the benefits of intraoperative cone-beam computed tomography (CBCT) with high image quality performed in a hybrid operating room. Intraoperative CBCT is easy to perform in a hybrid operating room, and it is possible to quickly evaluate high-quality CT images, including 3D images. Because the state of reduction of mandibular condylar fractures also affects the prognosis of treatment, more precise reduction and fixation should improve prognoses. The use of CBCT in a hybrid operating room also avoids re-operation, and patients benefit from minimum invasive surgery. Intraoperative CBCT is a very useful strategy for evaluation of mandibular condylar fracture surgical treatment.

The high sub-mandibular approach: Our experience about 496 procedures

INTRODUCTION

The potential drawbacks of surgical approaches to neck and base fractures of the mandibular condyle (visible scare, facial nerve injury) are still considered by many surgeons as a brake for open reduction and internal fixation. The aim of our study was to analyze the results in terms of access, scare quality and complications that could be noticed in a 12 years period of time with the use of the high sub-mandibular approach (HSMA) we first described in 2006 for the surgical treatment of neck and base fractures.

MATERIAL AND METHOD

All the files of patients operated on for condylar neck and base fractures approached by mean of a HSMA between January 2006 and December 2018 in our department and containing information concerning age, sex, type of fracture, kind of osteosynthesis material, operating time, name of the surgeon, postoperative complication linked to the approach, scare quality at 6 months follow-up at least were included. The skin incision and the dissection planes followed the original publication of Meyer et al. in 2006.

RESULTS

434 patients (sex ratio: 2.06, mean age: 32, 496 approaches) met the inclusion criteria. Following the AO classification, 21.2% of the fractures were classified as neck fractures and 78.8% as base fractures. 97.6% of all fractures were stabilized by mean of a 3D plate (TCP® plate, Medartis, Basel-CH), the remaining ones by mean of a combination of 1.2, 1.5 and 2.0 straight plates. Mean operating time was 40minutes per side. Patients were operated on by senior surgeons in 71.7% of the cases and by trainees under supervision for the others. Concerning the complications linked to the approach, we noticed 11 (2.2%) temporary (0 definitive) paresis of the facial nerve, 1 (0.2%) hematoma and 1 (0.2%) abscess that both needed revision. Scare was hypertrophic or considered as unaesthetic by the patient in 5 cases (1%).

DISCUSSION

The HSMA, if performed as initially described, is a safe and quick procedure compared to other cutaneous approaches. It gives access to all base fractures and to most of neck fractures. The very low rate of facial nerve complications is mainly explained by the plane by plane dissection making it very easy to avoid the facial nerve branches or to check them when encountered. The HSMA is particularly suited to the use of TCP plates as the upper holes of these plates, placed horizontally, are easy to reach from below. The HSMA is therefore still our preferred cutaneous approach to the condylar process.