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

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.

Condyle head fracture management: A systematic review of outcomes

The management of Condylar Head fractures (CHFs) has historically been with closed treatments(CTR); however, contemporary studies suggest that Open Reduction and Internal Fixation(ORIF) may produce better clinical and radiographic results. Our primary aim was to review the literature on the clinical and radiological outcomes of open and closed management of CHFs. A systematic literature search was undertaken using EMBASE, MEDLINE and PubMed, using PRISMA guidelines, for all studies relating to outcomes following CHF. The inclusion criteria include 1) studies focused on CHF in adult patients that included at least 20 cases 2) published in English language. ROBINS-1 tool was used for risk assessment. Data extracted was analysed and compared using the relative risks. A total of 29 studies reporting on 1550 ORIF and 798 CTR were included. ORIF resulted in significantly less trismus (RR 9.5), chin deviation (RR 7.3), malocclusion (RR 6.5), TMJ clicking (RR 4.3) and pain(RR 12.6) than CTR. Due to the substantial heterogeneity of studies, firm conclusions are difficult but there does appear to be objective benefits in outcomes following ORIF than CTR. Satisfactory results may however be achieved with CTR. Further large studies using standardised outcome measurements will be required to help elucidate exactly which CHF are best served by ORIF.

Virtual surgical planning is a useful tool in the surgical management of mandibular condylar fractures

PURPOSE

The aim of this study is to evaluate the application value of virtual surgical planning in the management of mandibular condylar fractures and to provide a reliable reference.

METHODS

This was a prospective randomized controlled study and recruited 50 patients requiring surgical treatment for their mandibular condylar fractures. The inclusion criteria were patients (1) diagnosed with a condylar fracture by two clinically experienced doctors and required surgical treatment; (2) have given consent for the surgical treatment; and (3) had no contraindications to the surgery. Patients were excluded from this study if: (1) they were diagnosed with a non-dislocated or only slightly dislocated condylar fracture; (2) the comminuted condylar fracture was too severe to be treated with internal reduction and fixation; or (3) patients could not complete follow-up for 3 months. There were 33 male and 17 female patients with 33 unilateral condylar fractures and 17 bilateral condylar fractures included. The 50 patients were randomly (random number) divided into control group (25 patients with 35 sides of condylar fractures) and experimental group (25 patients with 32 sides of condylar fractures). Virtual surgical planning was used in the experimental group, but only clinical experience was used in the control group. The patients were followed up for 1, 3, 6 and 12 months after operation. Variables including the rate of perfect reduction by radiological analysis, the average distance of deviation between preoperative and postoperative CT measurements using Geomagic software and postoperative clinical examinations (e.g., mouth opening, occlusion) were investigated for outcome measurement. SPSS 19 was adopted for data analysis.

RESULTS

The average operation time was 180.60 min in the experimental group and 223.2 min in the control group. One week postoperatively, CT images showed that the anatomic reduction rate was 90.63% (29/32) in the experimental group and 68.57% (24/35) in the control group, revealing significant difference (X² = 4.919, p = 0.027). Geomagic comparative analysis revealed that the average distance of deviation was also much smaller in the experimental group than that in the control group (0.639 mm vs. 0.995 mm; t = 3.824, p < 0.001).

CONCLUSION

These findings suggest that virtual surgical planning can assist surgeons in surgical procedures, reduce operative time, and improve the anatomic reduction rate & accuracy, and thus of value in the diagnosis and treatment of condylar fractures.

Advanced Three-Dimensional Technologies in Craniofacial Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the evolution of three-dimensional computer-aided reconstruction and its current applications in craniofacial surgery. 2. Recapitulate virtual surgical planning, or computer-assisted surgical simulation, workflow in craniofacial surgery. 3. Summarize the principles of computer-aided design techniques, such as mirror-imaging and postoperative verification of results. 4. Report the capabilities of computer-aided manufacturing, such as rapid prototyping of three-dimensional models and patient-specific custom implants. 5. Evaluate the advantages and disadvantages of using three-dimensional technology in craniofacial surgery. 6. Critique evidence on advanced three-dimensional technology in craniofacial surgery and identify opportunities for future investigation.

SUMMARY

Increasingly used in craniofacial surgery, virtual surgical planning is applied to analyze and simulate surgical interventions. Computer-aided design and manufacturing generates models, cutting guides, and custom implants for use in craniofacial surgery. Three-dimensional computer-aided reconstruction may improve results, increase safety, enhance efficiency, augment surgical education, and aid surgeons' ability to execute complex craniofacial operations. Subtopics include image analysis, surgical planning, virtual simulation, custom guides, model or implant generation, and verification of results. Clinical settings for the use of modern three-dimensional technologies include acquired and congenital conditions in both the acute and the elective settings. The aim of these techniques is to achieve superior functional and aesthetic outcomes compared to conventional surgery. Surgeons should understand this evolving technology, its indications, limitations, and future direction to use it optimally for patient care. This article summarizes advanced three-dimensional techniques in craniofacial surgery with cases highlighting clinical concepts.

Accurate Treatment of Condylar Fracture Assisted by Three-Dimensional Prototype and Bioresorbable Plates

PURPOSE

Although open treatments of condylar fracture have become the conventional treatment option, the accuracy is often not guaranteed. The purpose of this study was to improve the accuracy of fracture reduction assisted by three-dimensional (3D) prototype and bioresorbable plates in the treatment of condylar fractures.

METHODS

This was a prospective cohort study. Patients with condylar fractures were treated by surgery from October 2017 to November 2019 at School of Stomatology of China Medical University (Shenyang, China). The patients in the experimental group were treated with 3D-prototype and fixed with absorbable plates. Patients in the control group were treated routinely reduction and fixed with absorbable plates. Primary predictor variables were surgical treatment. Primary outcome was accurate reduction. Secondary outcomes were postoperative efficacy including maximum mouth opening, occlusal status, lateral excursion movements, and patient satisfaction. Other variables of interest included age, sex, type of patients. Continuous variables are reported as mean ± standard deviation. χ² test and t test were used for analysis.

RESULTS

The sample was composed of 48 patients (65 sides) who were treated surgically (25 men, 23 women; mean age, 39.50 year; range, 17 to 65 year) ; 27 patients (38 sides) were treated with the 3D-prototype approach and 21 patients (27 sides) were treated with the traditional approach. All 48 patients completed reduction and fixation of fractures. Preoperative and postoperative CT comparisons showed that 4 patients did not achieve accurate reduction, all in the control group, of which 3 patients had occlusal disorder. All patients in the experimental group achieved accurate reduction, of which 1 patient had occlusal disorder.

CONCLUSION

Our results suggest that using 3D prototype for bending the bioresorbable plate is an effective method for accurate treatment of condylar fracture.

Biomechanical evaluation of type p condylar head osteosynthesis using conventional small-fragment screws reinforced by a patient specific two-component plate

BACKGROUND

The aim of this study was to evaluate via finite element analysis (FEA) the biomechanical behavior of conventional small-fragment screws reinforced by a patient-specific plate in type p condylar head.

METHODS

A finite element model of the mandible was created using Mimics 12.1 software. A type p condylar head fracture was simulated in the right condyle, and the left condyle was used as a control. Two patterns of fixation were investigated: conventional two-screw fixation and the same fixation system reinforced with a small, patient-specific plate. Surface models were imported into the software Ansys 5.7for further volume mesh generation.

RESULTS

The highest stress gradients were observed in the cortical layer of the lateral fragment, located near the screw. The conventional fixation method resulted in equivalent stresses 2 to 10 times greater than the reinforced method. Rigidity of fixation in the reinforced method increased up to 1.25-3 times compared to the conventional two-screw technique.

CONCLUSION

This study's findings suggest significant benefits in unfavorable biomechanical conditions from reinforcement of the standard two-screw fixation of condylar head fractures with a small, patient-specific plate acting as a washer.

Application of CAD/CAM technology for surgical treatment of condylar head fractures: A preliminary study

Objectives

The aim of the present study was to improve the accuracy and reliability of ORIF in patients with condylar head fractures (CHFs) by developing a design for patient specific fixators, navigation and repositioning guides, as well as the algorithms of their clinical application.

Materials and methods

14 patients with 16 CHFs were treated by ORIF with the use of CAD/CAM technology. After virtual reduction of the bony fragments, the appropriate length and diameter of the screws was chosen. In biomechanically unfavorable cases (type p) patient specific reinforcement plates were used together with the positional screws for reinforcement of the bone-fixator system. And in cases of severely comminuted fractures patient specific 3-D plate was applied.

Results

The CT data, obtained immediately after the operation revealed the good anatomical reduction. Any deviations of the small fragments noted were near 1 mm in all cases. Postoperative clinical examination at 3 months follow up showed good occlusion and mouth opening not less than 3 cm in all patients. The lateral and anterior mobility of the mandible was restored with small limitations of protrusive mobility in 1 case. All the patients were satisfied with the outcomes.

Conclusions

The application of the CAD/CAM technologies and the new design of the surgical guides and patient specific reinforcement plates for CHFs helps to improve the accuracy and quality of fragments reduction and stability of fixation with minimal risks of intraoperative complications.

Clinical relevance

CAD/CAM technologies improve the clinical effectiveness of treatment patients with the CHFs.

Management of Nonunion and Malunion After Primary Mandibular Condylar Fracture Treatment: A Review and Recommendations

PURPOSE

After primary treatment of mandibular condylar fractures, nonunion and malunion can result in considerable malocclusion and temporomandibular joint dysfunction owing to the integral role the condylar head plays in the temporomandibular joint. At present, the choice and timing of treatment are highly heterogeneous. The purpose of this study was to evaluate the current literature to identify possible pitfalls, discuss available treatment options, and make recommendations.

METHODS

The electronic databases PubMed, MEDLINE, PROSPERO, CENTRAL (Cochrane Central Register of Controlled Trials), and Embase were searched for content matching mandibular condylar fracture "revision surgery," "secondary surgery," "refracture," "malunion," and "malunion osteotomy." Articles in English, limited to human adults, published in the past 10 years, with abstracts and full text available and appropriate study designs, were included.

RESULTS

A total of 101 articles were retrieved for analysis, and 4 articles were included. Because of heterogeneity in these studies, a pooled analysis could not be performed.

CONCLUSIONS

Surgery can be considered as primary treatment of condylar fractures, and early detection of complications allows for early intervention, leading to better outcomes. Treatment of temporomandibular joint dysfunction is highly heterogeneous and ranges from nonsurgical measures to joint reconstruction. Unilateral malocclusion can often be corrected with unilateral surgery, but bilateral surgery may be indicated in select cases. Bilateral deformities often require bilateral mandibular surgery, but in cases with preserved symmetry, maxillary surgery can be performed.

Key points in surgical management of mandibular condylar fractures

Mandibular condylar fractures are among the most common facial fractures and some of the most difficult to manage. Opinions about the management of mandibular condylar fractures differ among surgeons. With the implementation of new technology, an increased understanding of fracture management, and better functional and morphological outcomes reported in the literature, open reduction and internal fixation is becoming many surgeons' preferred choice for the treatment of condylar fractures. Because surgical treatment of such fractures is complex, certain factors must be considered to achieve satisfactory outcomes. In this article, we summarise six key points in the management of mandibular condylar fractures: virtual evaluation of condylar fracture, a suitable surgical approach, good reduction, stable internal fixation, repair of the articular disc, and restoration of the mandibular arch width. We believe that these points will help to improve the prognosis of mandibular condyle fractures.