Variations in the retromandibular approach to the condyle-transparotid versus anteroparotid transmasseteric - a prospective clinical comparative study

Infection Rates of an Intraoral Versus Extraoral Approach to Mandibular Fracture Repairs are Equal: A Systematic Review and Meta-Analysis

PURPOSE

This study investigates whether the intraoral approach to mandibular open reduction and internal fixation, through exposure to the oral cavity's microbiome, results in higher infection rates compared to the extraoral approach, thus addressing a critical public health concern, potentially offering an opportunity to reduce health-care costs, and aiming to guide effective clinical practice.

METHODS

In this systematic review with meta-analyses, a review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A comprehensive literature search was conducted using Embase and PubMed for articles published between 1989 and 2023. Inclusion criteria targeted studies on open reduction and internal fixation mandibular fractures comparing intraoral and extraoral approaches and reporting infection rates. Exclusion criteria eliminated non-English articles, case reports, and studies with insufficient approach-specific data. The primary outcome was the postoperative infection rate, with surgical approach as the predictor. Covariates such as age, sex, diabetes, and smoking status were included when reported. Data were analyzed using R software, employing random-effects models due to anticipated heterogeneity (I2 statistics).

RESULTS

From 61 studies, 11 provided direct comparisons involving 1,317 patients-937 intraoral and 380 extraoral. Infection rates were 5.9% for intraoral and 10% for extraoral approaches. Pooled relative risk was 0.94 [95% confidence interval, 0.63, 1.39], suggesting no significant risk difference. Prevalence of infections was estimated at 9% for intraoral and 6.1% for extraoral procedures, with significant heterogeneity (I2 = 84% for intraoral and 56% for extraoral).

CONCLUSION

Our meta-analysis found no significant difference in infection rates between the two approaches. There is opportunity to expand on reporting complication rates comparing the various approaches to mandibular fixation. Until these data are presented, surgeon preference may dictate the operative approach to expose the mandible for reduction and fixation.

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.

Prevalence of surgical site infections after open reduction and internal fixation for mandibular fractures: a systematic review and meta-analysis

Our study aims to estimate the prevalence of surgical site infections (SSI) following open reduction and internal fixation (ORIF) for mandibular fractures and to determine the effect of potential moderators on it. A systematic literature search (Medline and Scopus databases) was conducted independently by two reviewers. The pooled prevalence with 95% confidence intervals was estimated. Quality assessment as well as outlier and influential analysis were performed. Additionally, subgroup and meta-regression analysis were conducted in order the effect of categorical and continuous variables on the estimated prevalence to be investigated. In total, seventy-five eligible studies (comprising a sum of 5825 participants) were included in this meta-analysis. The overall prevalence of SSI following ORIF for mandibular fractures was estimated as high as 4.2% (95% CI 3.0-5.6%) with significant heterogeneity between studies. One study was identified to be critically influential. In the subgroup analysis, the prevalence was 4.2% (95% CI 2.2-6.6%) among studies conducted in Europe, 4.3% (95% CI 3.1-5.6%) among studies conducted in Asia and higher among those conducted in America (7.3%) (95% CI 4.7-10.3%). It is important for healthcare professionals to be aware of the etiology of these infections, despite the relatively low rate of SSI in these procedures. However, further, well-designed prospective and retrospective studies need to be conducted in order this issue to be fully clarified.

Pre-auricular Transparotid Approach for the Management of Mandibular Condylar Fracture: An Experience of 82 Cases

Purpose

This paper retrospectively analyses the functional outcomes and complications associated with pre-auricular transparotid approach for the management of mandibular condylar fractures.

Material and Methodology

The retrospective data of 82 condylar fractures were analysing in 73 patients who underwent open reduction and internal fixation with pre-auricular transparotid approach. Evaluation of post-operative complications and the post-operative occlusion status, maximal inter-incise opening, adequacy of reduction and stability of fixation were assessed clinically and radiographically.

Results

The exposure of fracture segment was adequate in all the cases, and fixation was easy with 2 mm delta miniplate. Transient facial nerve palsy occurred in 2 patients (2.43%). 1 patient developed sialocele which was managed conservatively. There were slight occlusal discrepancies in 10 patients at the end of 1-week follow-up which was corrected with guiding elastics at the end of 1-month follow-up. The reduction was adequate, and fixation was stable. The functional outcomes were satisfactory in term of mouth-opening and range of motion.

Conclusion

The pre-auricular transparotid approach provides direct access to the fracture site resulting in less retraction of the tissue containing facial nerve and also less amount of periosteal stripping is required, thus it maintains good vascularity to the fracture segments. It provides direct visualization of the fracture without much retraction of the tissue containing facial nerve branches. It allows better fixation of the fracture with very less complication which results in good functional outcomes.

Condylar Fractures: Multistep Surgical Planning by Mini-Invasive Approach, Patient Series

PURPOSE

Surgical treatment for condylar fractures is a challenging procedure most debated in scientific literature without a broad consensus on the selection of surgical techniques to be used and relative indications.The goal of this work is to propose a multistep surgical planning for condylar fractures based on an effective mini-invasive approach and safe procedure aimed to avoid as much as possible skin incision in the aesthetic areas of the face and neck, to decrease the risk of facial nerve injury.

METHODS

Ten patients with dislocated condylar neck fractures and sub-condylar fractures were included in this study.All the patients were studied with radiological images, computed tomography scans with three-dimensional reconstructions preoperatively and immediate postoperatively.Patients were evaluated pre- and post-operatively for dental occlusion, bone fragment alignment after reduction and after fixation, facial nerve functionality, skin scarring, temporomandibular joint functionality, temporomandibular joint symptomatology, and patient satisfaction.

RESULTS

Results were satisfactory for different parameters evaluated. No significant complications resulted in follow-up, particularly for facial nerve injury. By using this multistep procedure with each stage functional to the following one, the authors achieved satisfactory results following treatment of dislocated condylar fractures.

Retromandibular Transparotid Approach for the Treatment of Benign Nontraumatic Conditions of the Mandible. A Retrospective Consecutive Case-Series Study

ABSTRACT

The retromandibular transparotid approach enables the most direct access to the central and posterior part of the mandibular ramus including the condylar region. So far it has not been widely used for the management of benign pathology of the mandible. The purpose of this study was to evaluate the utilization rate of this approach in the nontrauma setting including the determination of suitable indications for this access. In total, 105 patients with 107 retromandibular transparotid approaches performed in the 6.5 years (from May 2014 to November 2020) were evaluated. Patients suffering from nontrauma pathology accounted for 4.7% of all cases. The recurrences of different types of odontogenic cysts and secondary chronic osteomyelitis were surgically managed via this approach with aesthetically acceptable resultant scar achievement and no identified postoperative complications. All lesions resolved and no recurrences occurred during the follow-up 32.0 ± 20.7 months (range 6 to 59 months, median = 26 months). The retromandibular transparotid approach may be considered for the enucleation of benign bone lesions in selected patients. Another type of surgery for the management of benign nontraumatic conditions in an accessible area without requirements for continuity resection and jaw reconstruction may be also suitable for using this approach.