A cadaveric and clinical evaluation of endoscopically assisted zygomatic fracture repair

Management of Zygomatic Arch Fractures by Intraoral Open Reduction and Transbuccal Fixation: A Technical Note

Fractures of the zygomatic arch are common due to its anatomical prominence. The post-traumatic restoration of the arch form is important to maintain the midfacial symmetry and anteroposterior projection of the face. Open reduction and internal fixation (ORIF) of fractured arch is indicated in specific clinical presentations. The traditional methods of ORIF of zygomatic arch fractures require cutaneous incisions, which are associated with complications such as scarring and facial nerve injury. This article presents a simple technique of "intraoral reduction and transbuccal fixation" of the arch that negates the problems associated with the conventional approaches to ORIF.

Endoscopic-Assisted Zygomatic Arch Fracture Repair With a Preauricular Approach

Introduction

Because of numerous negative sequelae with open techniques, endoscopic techniques are beginning to be widely used for maxillofacial fractures. Many endoscopic approaches for this area have been described according to several dissection plans and incisions. The aim of the present study was to report a new surgical incision and dissection method for zygomatic arch fracture that aims at reducing the complication rate of previously defined techniques.

Material and Methods

The authors operated on 8 patients with a new endoscopic-assisted surgical technique. This study focused on evaluating the complication rate and surgical comfort of these patients.

Results

Of the 8 patients, the plate was palpable in the zygomatic arch in one. No complications occurred due to this technique during the 1-year follow-up. Symmetrical facial contour and inconspicuous scars were obtained in all patients. Average operative time was 3 hours; hospitalization time was 1.6 days.

Conclusion

This study demonstrates that an endoscopic-assisted surgical approach with a preauricular mini-incision can be safely performed in isolated multifragment zygomatic arch fractures. Using individually designed plates improved our results. This technique is easy to apply, its cosmetic results are good, and its complication rate is low.

Endoscopic-Assisted Intraoral Open Reduction Internal Fixation of Mandibular Subcondylar Fractures: Initial Experiences from a Tertiary-Care Maxillofacial Center in India

Management of condylar fractures is a highly controversial and debatable area. Open reduction and internal fixation (ORIF) using an extraoral approach has certain benefits over the nonsurgical treatment. Risk of damage to the facial nerve and an extraoral scar remains constant deterrents. An endoscopic-assisted ORIF offers an intraoral approach, thus eliminating consequences such as scarring. Though this technique offers unparalleled advantages, it is associated with a steep learning curve. Surgical results improve only with patience and experience. Patients with condylar fractures reported to SDM Craniofacial Unit, Dharwad, India, from 2013 to 2015 are included. Patients were treated with endoscopic-assisted ORIF and were evaluated for functional outcomes that included occlusion, maximal interincisal opening, and deviation of mouth and complications such as facial nerve pareses, postsurgical infection, and morbidity. Fifteen patients included in the study: 4 left sided and 11 right sided fractures. Nine patients had associated other mandibular fracture. Mean age of the patients was 28.2 years. Mean mouth opening at the end of 1 week, 6 weeks, and 6 months was 32.6, 37.8, and 40.5 mm, respectively. Transient facial nerve pareses were noted in one patient, and an extraoral draining sinus was noted in another. Endoscopic-assisted ORIF has a definite scope in management of condylar fractures. Results are more predictable with appropriate case selection due to a steep learning curve and intraoperative technical challenges. An initial experience in ORIF using extraoral approaches would greatly benefit a surgeon in utilizing this novel and alternate tool.

Endoscopic Approach to Orbital Blowout Fracture Repair

OBJECTIVES: Transconjunctival and subciliary approaches to orbital floor blowout fractures (OBF) have known risks of postoperative eyelid malposition. This study evaluates the endoscopic transmaxillary repair of OBFs in a cadaveric model and clinical setting.

METHODS: Sixteen cadaveric and 10 clinical OBFs were repaired endoscopically. A Caldwell-Luc approach and modified sinus surgery instrumentation were used to repair each fracture. Variations in fracture pattern, instrumentation, and surgical technique were evaluated.

RESULTS: Endoscopic repair was achieved in all 16 cadaveric orbits and in 9 of 10 patients. Fracture patterns were classified as either medial or lateral to the infraorbital nerve. Average clinical operating time was 1:38. Of 9 postoperative CT scans, 5 were rated as excellent, 3 as good, and 1 as poor.

CONCLUSIONS: The endoscopic transmaxillary approach is a safe, viable technique for OBF repair. It offers improved visualization, anatomic fracture repair, no risk of postoperative eyelid complications, and good clinical results. EBM rating: C.

Clinical Follow-up on Sagittal Fracture at the Temporal Root of the Zygomatic Arch: Does It Need Open Reduction?

Background

The zygoma is a major portion of the midfacial contour. When deformity occurs in this area, a reduction should be conducted to correct it. If a sagittal fracture at the temporal root of the zygomatic arch occurs, this also requires reduction, but it is difficult to approach due to its anatomical location, and the possibility of fixation is also limited. Thus, the authors attempted the reduction of sagittal fracture by two- or three-point fixation and the Gillies approach without direct manipulation. The preoperative and postoperative results of the patients were evaluated. Follow-up was performed to establish a treatment guideline.

Methods

A retrospective study was done with 40 patients who had sagittal fractures at the temporal root of the zygomatic arch from March 2009 to June 2012. Only two- or three-point fixation was performed for the accompanying zygomatic-orbital-maxillary fracture. The Gillies approach was used for complex fractures of the zygomatic arch, while the temporal root of the zygomatic arch was only observed without reduction. Preoperative and postoperative computed tomography and X-ray scans were performed to examine the results.

Results

The result of the paired t-test on preoperative and postoperative bone gap differences, the depression level, and the degree of temporal protrusion showed a marked decrease in the mean difference at a 95% confidence interval. The results were acceptable.

Conclusions

In the treatment of sagittal fractures at the temporal root of the zygomatic arch, it is acceptable to use indirect reduction and non-fixation methods. This leads to a satisfactory aesthetic and functional outcome.

Transnasal endoscopic repair of posterior table fractures

OBJECTIVES/HYPOTHESIS

Conventional treatment of frontal sinus posterior table fractures has included osteoplastic flap or cranialization procedures despite considerable advances in endoscopic technique and experience. The objective of the current study was to evaluate outcomes of frontal sinus fractures involving the posterior table managed using endoscopic approaches.

STUDY DESIGN

Prospective cohort.

SETTING

Tertiary care, academic university hospital.

METHODS

Prospective evaluation of patients with posterior table fractures was performed. Data were collected regarding demographics, etiology, technique, operative site, length involving the posterior table, size of the skull base defect, complications, and clinical follow-up.

RESULTS

Thirteen patients (average age 37 years) with posterior table fractures were treated using endoscopic techniques from 2008 to 2012. Mean follow-up time was 68 weeks (range, 2-206 weeks). Patients were primarily managed using Draf IIb frontal sinusotomies with 1 individual requiring a concomitant trephine. A Draf III procedure was performed in 1 patient. Average fracture defect (length vs width) was 13 × 4.5 mm, and average length involving the posterior table was 9.7 mm (1-30 mm). Skull base defects were covered with a septal flap and/or free tissue grafts. Although 1 individual required a revision frontal sinusotomy and follow-up was short in several patients, all sinuses remained patent on last clinical examination.

CONCLUSION

Management of frontal sinus posterior table fractures using minimally invasive endoscopic techniques provides excellent outcomes in selected cases. Fractures of up to 30 mm in length were adequately managed in this series and indicate this approach can be a viable alternative in the treatment of these fractures.

Etiology and Management of Zygomaticomaxillary Complex Fractures in the Armed Forces

BACKGROUND

The nature of duties in the Armed Forces predisposes its personnel to various kinds of injuries. The rise in violence coupled with an exponential increase in motorized population has contributed towards maxillofacial injuries. The aim of this study was to determine the incidence, cause and pattern of various injuries resulting in fracture of the zygomaticomaxillary complex in Armed Forces personnel and their families.

METHODS

A study was conducted between January 2001 - December 2002 in maxillofacial surgical wing of an Army Dental Centre with specific regard to age, sex, location and etiology of zygomaticomaxillary complex fracture. Out of 201 maxillofacial injuries received, 87 individuals were treated for zygomaticomaxillary fractures. Majority of the individuals were in their third decade of life and road traffic accident was the leading cause of the fractures.

RESULTS

Uneventful recovery was there in 81 individuals (93.10%). Six patients (6.89%) had post operative complications in the form of enophthalmos, hypophthalmos, paraesthesia, diplopia and facial asymmetry. These complications were subsequently treated successfully as a secondary procedure for all the patients.

CONCLUSION

Facial bones, especially of the middle third of the face, are composed of a network of fragile bones which give way in case of force to a lesser extent than other parts of the body. It is imperative to educate people regarding the importance of restraints and use of protective headgears/use of seat belts while travelling in motorized transport.

Minimally invasive endoscopic osteosynthesis for frontozygomatic fracture: a new approach

Miniplate fixation on the lateral face of the orbital rim using existing endoscopic methods for frontozygomatic fracture still has some disadvantages, such as cosmetic disturbance from the lateral brow incision for the trocar, and abnormal palpability of the miniplate. We applied a new method of endoscopic osteosynthesis by access through temporal incisions alone and miniplate fixation on the lateral temporal face of the frontozygoma. Postoperative courses were uneventful in all four cases treated, and we achieved cosmetic improvement (minimizing incision and scars) as well as decreased palpability of the miniplate.

Endoscopic approach to maxillofacial trauma

Endoscopic approaches to maxillofacial trauma have included their use in temporomandibular joint arthroscopy, zygomatic arch repair, repair after orbital trauma, repair of frontal sinus fractures, and finally in the repair of subcondylar mandibular fractures. These techniques provide exciting new options for the management of facial fractures. Many of the techniques provide a steep learning curve and require specialized equipment. The approach to an orbital blowout fracture allows the use of a Caldwell-Luc approach and the use of a naturally occurring body space (the maxillary sinus) for the visualization and maneuvering of the endoscope, tools, and implants. The use of the endoscope in the management of fractures for facial structures such as mandibular subcondylar fractures, which do not have a naturally occurring body cavity, may present greater challenges when trying to obtain visualization, reduction, and fixation. When used for the treatment of subcondylar fractures, wide exposure and the use of right-angled drills and screw drivers may significantly help with this procedure. This may be considered by some surgeons as an endoscopically "assisted" procedure that can possibly be accomplished with direct visualization and the use of dental mirrors. It remains to be seen as to whether some of these diverse endoscopic applications will represent the standard of care in the future or remain a specialized technique practiced by a minority of surgeons in a few specialized centers. This article reviews various endoscopic applications to maxillofacial trauma and discusses some of the controversies of these techniques.

Endoscopic management of facial fractures

PURPOSE OF REVIEW

Endoscopic applications in otolaryngology continue to expand, most recently in the area of maxillofacial trauma. Endoscopic management of orbital blow-out, frontal sinus, zygomatic arch, and subcondylar fractures has been described. This paper reviews the current literature including new techniques, indications, and outcomes in endoscopic management of facial fractures.

RECENT FINDINGS

Very few large studies of endoscopic fracture repair exist. The current literature, however, suggests that, when compared with an open approach, smaller endoscopic incisions result in reduced patient morbidity with similar outcomes. Dedicated endoscopic instrumentation and novel surgical approaches continue to be developed.

SUMMARY

Endoscopic repair of facial fractures is a new and evolving technique that offers the potential for reduced patient morbidity and operating time, as well as quicker patient recovery. Current applications include the management of orbital blow-out, frontal sinus, zygomatic arch, and subcondylar fractures. It should be emphasized that endoscopy augments, rather than replaces, the 'time tested' principles of adequate skeletal exposure, accurate fracture reduction, and appropriate internal fixation.

Endoscopic Management of Frontal Sinus Fractures

Endoscopes have had a profound effect on nearly every surgical specialty over the past 20 years. Using endoscopic approaches, excellent visualization of the surgical site can be achieved while avoiding extensive external incisions, thus, dramatically reducing morbidity compared with traditional surgical approaches. This article outlines the state of the art with regard to the use of endoscopes for managing frontal sinus fractures, which are one of the most common fractures treated with endoscopic techniques.

Treatment of Noncomminuted Zygomatic Fractures With Percutaneous Screw Reduction and Fixation

The standard treatment modality of zygomatic fractures is open reduction and rigid fixation of the fractured segments. Although most of the zygomatic fractures deserve this attentive surgical manipulation to prevent late residual asymmetry, minimally depressed noncomminuted zygomatic fractures can be reduced and fixed percutaneously. Percutaneous intervention causes minimal scarring and morbidity than open techniques and it is possible to align fragments precisely by using high-quality three-dimensional computed tomography (3-D CT) imaging. Six patients with noncomminuted fractures of the zygomaticomaxillary skeleton were evaluated with plain radiographs of facial bones, axial, coronal and 3-D CT. Reduction of the displaced bone segments were achieved by traction of percutaneously applied screw. Either reduced segments were not fixated at all or one of the two new fixation techniques, described in detail in the article, were used for stabilization of reduced segments. In all patients, accurate reduction was obtained. None of the patients showed any recurrent displacement or infection during the follow-up period of six months. The screws were removed in the clinical settings without difficulty. Although percutaneous reduction and external fixation of noncomminuted zygomatic fractures has limited indications, it has its own advantages over open techniques. This method is a less invasive technique and can be performed without any problem in selected cases. Our technique is not suitable for complex zygomatic and periorbital fractures.

Endoscopic Management of Frontal Sinus Fractures

Endoscopes have had a profound effect on nearly every surgical specialty over the past 20 years. Using endoscopic approaches, excellent visualization of the surgical site can be achieved while avoiding extensive external incisions, thus, dramatically reducing morbidity compared with traditional surgical approaches. This article outlines the state of the art with regard to the use of endoscopes for managing frontal sinus fractures, which are one of the most common fractures treated with endoscopic techniques.

The Rationale and Technique of Endoscopic Approach to the Zygomatic Arch in Facial Trauma

The reliable form and strategic position of the zygomatic arch make it a valuable landmark in midfacial trauma management. The benefits of arch repair have been used infrequently, mainly because traditional coronal access to this structure is fraught with undesirable sequelae. Endoscope-assisted zygomatic arch realignment and fixation allow anatomic repair without sustaining the drawbacks of extensive access incisions. The relative importance of this approach increases with trauma complexity, being most useful in Le Fort III and complex zygoma injuries.

[Management of zygomatic fractures via a transconjunctival approach with lateral canthotomy while preserving the lateral ligament]

INTRODUCTION

This study reports on a modified approach to treat zygomatic fracture. For the surgical approach, a transconjunctival incision and, instead of a lateral canthotomy, a superficial incision of the skin and subcutaneous tissue was used, preserving the lateral ligament. The results are compared with those of previous techniques, especially the subciliary incision.

PATIENTS

In a prospective study, 30 patients (9 females and 21 males, mean age 32.1 years) with zygomatic fractures were operated using this approach. Mean follow-up time was 6 months after removal of the plates. Fractures were caused by trauma due to fighting, bicycle falls, or sport accidents. Follow-up radiographs were used to evaluate the position of the zygoma after reduction and rigid fixation.

RESULTS

Reduction and rigid fixation of the fractures were possible to perform in all cases. The access to the orbital floor and the exposure of the inferior and lateral rim were satisfactory and an additional latero-orbital cut was not necessary. The disadvantage of the complete incision of the lateral ligament with the necessity of intraoperative refixation and possible ectropium of the eyelid could be avoided. Injuries or infections of the cornea or the bulbus did not occur. Postoperative complications such as scar formation resulting in entropium or ectropium were not seen.

CONCLUSION

These results show that the transconjunctival approach with lateral superficial incision preserving the lateral ligament for treatment of zygomatic fractures is satisfactory in all cases of rigid fixation of both inferior and lateral rims. Because of its esthetic and functional advantages this approach has become standard in our department.

Endoscopic repair of isolated anterior table frontal sinus fractures

BACKGROUND

Recently developed endoscopic brow-lifting techniques and instrumentation are being used for treatment of anterior table frontal sinus fractures. Potential endoscopic treatment options include fracture reduction with or without plating and fracture repair with hydroxyapatite bone cement (HA).

OBJECTIVE

To evaluate the efficacy of miniplates and HA for repair of anterior table fractures.

METHODS

Frontal sinus fractures were generated in 11 cadavers. Standard endoscopic brow-lifting techniques were used to visualize the fracture from above. A 1-cm Lynch incision was used to apply instrumentation from below. Fractures were repaired with either miniplate reduction or HA recontouring.

RESULTS

All fractures were exposed without difficulty. Miniplates were applied in 5 specimens: 1 specimen had a complete reduction, 2 specimens had partial reductions, and 2 specimens had incomplete reductions. Bone cement was applied in 9 specimens: 4 specimens were rated as excellent and 5 specimens as good.

CONCLUSIONS

Frontal sinus fractures can be successfully exposed and repaired with an endoscopic technique. Endoscopic miniplate reduction of frontal sinus fractures can be accomplished. However, it is challenging, and success rates vary depending on fracture comminution. Endoscopic HA recontouring offered the best results, with good or excellent outcomes in all specimens.

Deep dissection plane for endoscopic-assisted comminuted malar fracture repair

Endoscopic technique has been used in the management of comminuted malar fractures. However, the reported dissection plane is close to the frontal branch of the facial nerve, and paralysis of the frontal muscle is sometimes noted postoperatively. From January 1998 to November 2001, 42 patients underwent endoscopic-assisted zygomatic bone repair at Kaohsiung Medical University Hospital and Kaohsiung Municipal Hsiao Kang Hospital. The zygomatic arch was approached via a dissection plane beneath the deep temporal fascia, and the plate was fixed on the upper border of the arch. The advantages of this method are 1) one temporal incision is sufficient for dealing with the zygomatic arch fracture; 2) the learning curve for endoscopic technique is shortened; 3) there is less risk of injury to the frontal branch of the facial nerve; and 4) the periosteum at the anterior and inferior border of the zygomatic arch is preserved. The deep method is a safe alternative for endoscopic-assisted comminuted malar fracture repair.

Endoscopically assisted zygomatic fracture reduction and osteosynthesis revisited

In comminuted fractures of the zygoma open reduction of the malar arch is essential for correct anatomic repair. Avoiding exposure of this landmark may result in severe functional and aesthetic impairment. Exposure of the malar arch necessitated traditionally a coronal incision. However, recently several authors reported good results in malar fracture repair with minimal incisions and endoscopic assistance. To establish this technique a cadaver study was performed. Different approaches to the malar arch, fracture reduction and internal fixation were evaluated. After establishment of a satisfactory technique 12 patients with comminution of the zygoma were treated with endoscopic assistance. Repositioning of the fragments was excellent in nine cases, minimal remaining dislocation was seen in two cases and in one case revision was necessary. Postoperatively the frontal branch of the facial nerve was intact in all patients. Scarring was minimal. In three patients plating of the malar arch on a side table resulted in arch necrosis and resorption in the long-term follow-up. Operating time was remarkably longer than in conventional procedures due to the difficult technique.

Endoscopically assisted, intraorally approached corrective rhinoplasty

In the field of facial surgery, operations that require guesswork can result in unexpected complications. One example of such "blind" facial surgery is the lateral osteotomy procedure in corrective rhinoplasty. In most conventional corrective rhinoplasties, the postoperative results of a lateral osteotomy can be controlled by the surgeon's visual perception or manual dexterity; therefore, an experienced surgeon is indispensable in such elaborate operations. Until now, reports have focused on the endoscopic approach through the nasal dorsum or septum through the nostril. However, because of the difficulty in handling the endoscope with osteotomy instruments, it is considered difficult to perform a precise lateral osteotomy procedure using that approach. The authors think the intraoral endoscopic approach should be considered a viable alternative in corrective rhinoplasty. Through small, bilateral gingivobuccal incisions, both the piriform apertures and nasal bones can be easily exposed, and the exact level of the lateral osteotomy can be confirmed directly under the endoscope. The lateral osteotomy is made simply with a reciprocating saw, and symmetrical cutting can be ascertained during the operation. Sometimes, a particular osteotomy level or the proper repositioning of osteotomed segments can be readily evaluated with assistance from the endoscope during the operation. Eleven cases using this procedure were performed over the past 3 years. These endoscopic repairs for a deviated nose were quite helpful for visual confirmation and accurate correction. No complications occurred when using the endoscope with this procedure.

Application of endoscope in zygomatic fracture repair

The endoscope has been used to visualise the upper face and brow in aesthetic facial surgery which is performed without a coronal incision. We applied these principles to repair zygomatic fractures with the aid of a 4 mm, 30 degree telescope inserted through a small temporal incision. Fracture sites at the zygomatic arch and the zygomaticofrontal suture were exposed and fixed with miniplates under endoscopic control. This technique was used in 15 consecutive patients including 2 with isolated zygomatic arch comminuted fractures and 13 having displaced zygomatic fractures with segmental, displaced zygomatic arch fractures. Nine patients were men and six patients were women with a mean age of 35 years. Three patients had associated mandibular fractures. The periods of follow-up ranged from 3 to 22 months. Two patients developed transient frontal nerve palsy which recovered within 2 months. One patient had mild temporal hollowing on the side of the facial fracture. All patients achieved the adequate anatomic reduction and satisfactory malar symmetry. There has been no case of chewing problems, cheek numbness or progressive enophthalmos developing postoperatively. Application of the endoscope in zygomatic fracture repair minimises the scalp scar, avoids forehead numbness, provides a comfortable postoperative recovery and shortens hospital stay. Careful preoperative evaluation and proper surgical technique are mandatory for achieving optimal results in selected patients.

Application of minimal-access techniques in lag screw fixation of fractures of the anterior mandible

A modification of the traditional open methods for the surgical management of anterior mandibular fractures using the principles of minimal-access surgery is presented; it was successfully performed in five patients. This technique incorporates the use of lag screws introduced through small incisions transmucosally or percutaneously after anatomic reduction of the fracture, and it relies on accurate preoperative radiologic assessment of the fracture pattern and location. This technique is indicated for any favorable fracture in the anterior mandibular arch that could achieve osteosynthesis with lag screw fixation, and it depends on the use of a dental arch bar as a tension band. Contraindications include unfavorable fracture patterns (long oblique, comminuted, or flat mandibular plane), inadequate dental support to maintain an arch bar due to missing or loose teeth, the inability to determine the fracture pattern preoperatively, and operator inexperience. Potential advantages include a shorter operative time, economic savings, decreased patient morbidity (swelling, scarring, and mental nerve and lower-lip muscle dysfunction), and improvement in functional rehabilitation.

True intraoral reduction malarplasty with a minimally invasive technique

In the Orient, faces are usually wide and short. This physical characteristic is often undesirable in many Asian cultures. Consequently, reduction malarplasty is one of the most common aesthetic procedures performed in the Orient. Previously described techniques for malar reduction such as intraoral chiseling or the burring-down of the zygomatic body and arch often result in minimal invasiveness, with no external scarring. However, they are less effective techniques. Other techniques, such as osteotomy and repositioning of a prominent malar complex by means of a coronal approach also proved fallible, by often resulting in a prominent, visible scar. Furthermore, a combined approach, using both the intraoral and the external (preauricular or sideburn) routes, often results not only in an external scar, but also in possible facial nerve (frontotemporal branch) damage. Thus, we performed a true intraoral osteotomy and reduction malarplasty through upper buccal sulcus incisions, resulting in minimal tissue damage without external scarring. Aesthetic facial contouring surgery has been performed in increasing numbers over the past decade, especially for malar and mandibular angle protrusion. The prominence of the malar area varies according to differences in the inherited bony structure. Essentially, Orientals are mesocephalic, whereas Caucasians are dolichocephalic; the face is wider and shorter in the former than in the latter. An even greater prominence of the zygoma among Orientals, which causes the face to be wider and shorter, is widely regarded as an unattractive feature in the Oriental culture [1,2]. In contrast, a flat cheek bone in Caucasians makes the face appear masculine, in addition to making the nasal and chin prominences more noticeable. Of the previously described techniques for malar reduction, shaving and contouring by the intraoral approach, without the external approach [1,4] is often less effective due to the limitations of shaving. Likewise, osteotomy and repositioning of a prominent malar complex by the coronal approach can result in an extensive visible scar [2,5,6,12]. Additionally, the combined approach by means of the intraoral and external (preauricular or temporal, sideburn) routes [4,7] can result in an external scar and the distinct possibility of facial nerve damage [8]. Therefore, our team created a simple and effective way of conducting a true intraoral osteotomy and reduction malarplasty without external scarring and the instigation of facial nerve damage.

Endoscopic subcondylar fracture repair: functional, aesthetic, and radiographic outcomes

An endoscopic method of mandibular subcondylar fracture repair has been described recently. To determine the effectiveness of this new technique, we longitudinally studied functional, aesthetic, and radiographic parameters following endoscopic repair of 22 subcondylar fractures in 20 patients. Restoration of mandibular function was achieved without postoperative maxillomandibular fixation. Premorbid occlusion was restored. Clinical jaw motion was found to progressively increase with a mean interincisal jaw opening of 43 mm achieved after the eighth postoperative week. Patients were pleased with the aesthetic restoration of their chin projection,jaw line, and the symmetric midline movement of the chin point onjaw opening. Anatomic fracture reduction with rigid plate fixation was confirmed on early postsurgical radiographs. Late radiographs showed fracture union without remodeling of the condylar head. Endoscopic subcondylar fracture repair was efficacious at functional, aesthetic, and radiographic restoration of the mandible.