Functional and radiologic outcome of open reduction and internal fixation of condylar head and neck fractures using miniplate or microplate system

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.

Quantitative Assessment of Condylar Remodeling After Open Reduction and Internal Fixation in Mandibular Condylar Head Fractures

Open reduction and internal fixation (OR/IF) and closed treatments are viable options, with OR/IF gaining popularity in mandibular condylar head fracture (CHF). Sufficient research is lacking on long-term condylar morphologic changes. This study quantitatively evaluated the morphologic changes in the condylar head in patients who underwent OR/IF for CHF without the removal of osteosynthesis material. A retrospective study analyzed patients who underwent OR/IF for CHF between November 2010 and August 2022. The transverse/lateral condyle width and condyle height were radiologically analyzed using panoramic and reverse Towne view x-ray images at immediate (T0), short-term (T1), and long-term (T2) postoperative periods. The study involved 29 patients with 32 surgically treated CHF. Long-term condyle height decreased significantly from 18.9±0.8 mm at T0 to 18.1±0.8 mm at T1 (P=0.042), and further to 17.3±0.7 mm at T2 (P=0.034). Transverse width slightly reduced from 18.7±0.7 mm at T0 to 17.9±0.8 mm at T1 (P=0.001) but remained stable from T1 to T2 (17.6±1.0 mm, P=0.756). Following surgery, maximal mouth opening averaged 39.5±6.1 mm, with one case of chin deviation and three cases of joint pain. The condyle undergoes long-term shortening without altering its width. Nevertheless, patients experience favorable functional outcomes, including satisfactory mouth opening and occlusion. In addition, it is advisable not to remove the osteosynthesis material, as the remaining material causes minimal functional impairment and bone resorption.

Factors Affecting the Duration of Surgery in the Management of Condylar Head Fractures

Prolonged operation times should be avoided due to the associated complications and negative effects on the efficiency of the use of operating room resources. Surgical treatment of mandibular condylar head fractures is a well-established routine procedure at our department, nevertheless, we recognized fluctuating operating times. This study aims to pinpoint the influencing factors, in particular the hypothesis whether the efficiency of intraoperative muscle relaxation may decisively affect the duration of surgery. It analyses 168 mandibular condylar head fractures that were surgically treated in the period from 2007 to 2022 regarding the duration of the surgery and potential factors affecting it. The potential predictors' influence on the dependent variable operation time was mainly calculated as a bivariate analysis or linear regression. Efficiency of relaxation (p ≤ 0.001), fragmentation type (p = 0.031), and fracture age (p = 0.003) could be identified as decisive factors affecting the duration of surgery, as the first surgeon was a constant. In conclusion, surgical intervention should start as soon as possible after a traumatic incident. In addition, a dosage regimen to optimize the efficiency of relaxation should be established in future studies. Fragmentation type and concomitant fractures should also be considered for a more accurate estimation of the operating time.

No Significant Bone Resorption after Open Treatment of Mandibular Condylar Head Fractures in the Medium-Term

Open treatment of condylar head fractures (CHF) is considered controversial. In this retrospective cohort study our primary objective was therefore to assess bone resorption and remodeling as well as patients function after open treatment of CHF in a medium-term follow-up (15.1 ± 2.2 months). We included 18 patients with 25 CHF who underwent open reduction and internal fixation, between 2016 and 2021, in our analysis. The clinical data and cone-beam computed tomography (CBCT) datasets were analyzed. The condylar processes were segmented in the postoperative (T1) and follow-up (T2) CBCT scans. Volumetric and linear bone changes were the primary outcome variables, measured by using a sophisticated 3D-algorithm. The mean condylar head volume decreased non-significantly from 3022.01 ± 825.77 mm3 (T1) to 2878.8 ± 735.60 mm3 (T2; p = 0.52). Morphological alterations indicated remodeling and resorption. The pre-operative maximal interincisal opening (MIO) was 19.75 ± 3.07 mm and significantly improved to 40.47 ± 1.7 mm during follow-up (p = 0.0005). Low rates of postoperative complications were observed. Open reduction of CHF leads to good clinical outcomes and low rates of medium-term complications. This study underlines the feasibility and importance of open treatment of CHF and may help to spread its acceptance as the preferred treatment option.

The Stability Evaluation of Two Internal Fixation Patterns of Extracapsular Condylar Fracture Based on One Novel Measuring Method

PURPOSE

The most stable internal fixation pattern for extracapsular condylar fracture (ECF) has been controversial. In this study we aimed to evaluate the stability of 2 common internal fixation patterns using 1 or 2 miniplates separately. One novel measuring method based on the angle of miniplates' localization was introduced.

MATERIALS AND METHODS

Twenty-seven patients with 30 sides of extracapsular condylar fracture were enrolled in this retrospective study. All cases were performed open reduction and internal fixation using 1 or 2 titanium plates with both the postoperative immediate CT (T1) and the over 6 months' follow-up CT (T2). Mandibles and implants were segmented and reconstructed respectively using SIMPANT 14.04 software. For 1 miniplate group, the sagittal crossing angle (<1) between miniplate (P1) and posterior border of ipsilateral ramus was measured. For 2 miniplates group, the sagittal crossing angle (<2) between 2 miniplates (P2a, P2b) was measured. Both anteroposterior (∠AP) and mediolateral angle change (∠ML) of each miniplate between T1 and T2 was measured. The stability of 2 internal fixation patterns was measured and evaluated based on the angle change of miniplates. And also the stability of each internal fixation pattern could be investigated based on the relationship between the placement patterns of miniplates and the angle change.

RESULTS

Fifty-two miniplates were finally segmented and reconstructed successfully, including 8 of 1 miniplate group and 44 of 2 miniplate group. For 1 miniplate group, the average ∠AP and ∠ML were 6.10° and 8.54°, respectively. For 2 miniplate group, the average ∠AP and ∠ML of P2a were 3.02° and 2.56°, respectively, as well as 3.12° and 3.07° of P2b.

CONCLUSIONS

The novel measuring method based on the angle of miniplates' localization showed potential for the stability evaluation of internal fixation of condylar fracture. In summary, the internal fixation patterns using 2 miniplates shows better stability than that of 1 miniplate.

Efficacy of Microplates versus Miniplates in the Management of Maxillofacial Fractures

Introduction:

Increased facial trauma has led to advances in techniques of internal fixation, improvements in plating system, refinements in exposure of facial skeleton fueling the rapid use of internal fixation for the management of facial fractures. Evaluating 40 patients with confirmed midfacial (Le Fort I and II) and mandibular fractures, this study presents the efficacy of microplate in comparison with miniplate in terms of load bearing capacity, stability at the fracture site and postoperative palpability.

Objectives:

To evaluate the efficacy of microplates in comparison with miniplates in maxillofacial trauma.

Materials and Methods:

Study sample consists 40 subjects, 20 each in two groups clinically and radiographically diagnosed with Group 1 (maxillary) and Group 2 (mandibular fractures) which were subdivided into 10 each treated with miniplate and microplate respectively. Postoperatively, stability of fracture, bite force, need for postop MMF, pain, infection, wound dehiscence, mouth opening, occlusion and palpability was noted. All cases have been evaluated clinically for various parameters for minimum of 3 months to assess any postoperative complications.

Results:

We found microplates are stable enough and have adequate load bearing capacity. Due to close adaptability and less hardware, postoperative palpability is less but larger sample study with long term follow up is necessary to conclude its efficacy in load bearing fracture sites.

Biomechanical Loading Comparison between Titanium and Bioactive Resorbable Screw Systems for Fixation of Intracapsular Condylar Head Fractures

Osteosynthesis resorbable materials made of uncalcined and unsintered hydroxyapatite (u-HA) particles, poly-L-lactide (PLLA), are bioresorbable, and these materials have feasible bioactive/osteoconductive capacities. However, their strength and stability for fixation in mandibular condylar head fractures remain unclear. This in vitro study aimed to assess the biomechanical strength of u-HA/PLLA screws after the internal fixation of condylar head fractures. To evaluate their biomechanical behavior, 32 hemimandible replicas were divided into eight groups, each consisting of single-screw and double-screw fixations with titanium or u-HA/PLLA screws. A linear load was applied as vertical and horizontal load to each group to simulate the muscular forces in condylar head fractures. Samples were examined for 0.5, 1, 2, and 3-mm displacement loads. Two screws were needed for stable fixation of the mandibular condylar head fracture during biomechanical evaluation. After screw fixation for condylar head fractures, the titanium screws model was slightly more resistant to vertical and horizontal movement with a load for a small displacement than the u-HA/PLLA screws model. There was no statistically significant difference with load for large displacements. The u-HA/PLLA screw has a low mechanical resistance under small displacement loading compared with titanium within the limits of the mandibular head fracture model study.

Trismus in Face Transplantation Following Ballistic Trauma

BACKGROUND

Trismus can be a challenging consequence of ballistic trauma to the face, and has rarely been described in the setting of face transplantation. Almost half of all current face transplant recipients in the world received transplantation to restore form and function after a ballistic injury. Here we report our experience and challenges with long standing trismus after face transplantation.

METHODS

We reviewed the medical records of our face transplant recipients whose indication was ballistic injury. We focused our review on trismus and assessed the pre-, peri- and postoperative planning, surgery and functional outcomes.

RESULTS

Two patients received partial face transplantation, including the midface for ballistic trauma. Both patients suffered from impaired mouth opening, speech intelligibility, and oral competence. Severe scarring of the temporomandibular joint (TMJ) required intraoperative release in both patients, and additional total condylectomy on the left side 6 months posttransplant for 1 patient. Posttransplant, both patients achieved an improvement in mouth opening; however, there was persistent trismus. One year after transplantation, range of motion of the jaw had improved for both patients. Independent oral food intake was possible 1 year after surgery, although spillage of liquids and mixed consistency solids persisted. Speech intelligibility testing showed impairments in the immediate postoperative period, with improvement to over 85% for both patients at 1 year posttransplant.

CONCLUSIONS

Ballistic trauma to the face and subsequent reconstructive measures can cause significant scarring and covert injuries to structures such as the TMJ, resulting in long standing trismus. Meticulous individual planning prior to interventions such as face transplantation must take these into account. We encourage intraoperative evaluation of these structures as well as peri- and postoperative treatment when necessary. Due to the nature of the primary injury, functional outcomes after face transplantation in these patients may differ substantially from those of other indications.

Resorption behaviour of the articular surface dome and functional outcome after open reduction and internal fixation of mandibular condylar head fractures using small-fragment positional screws

PURPOSE

The aim of the study was to evaluate the resorption of the mandibular condylar head after open reduction and internal fixation of fractures with small-fragment screws and to evaluate the functional outcome.

PATIENTS AND METHOD

Forty-eight patients (55 condylar head fractures) underwent surgical treatment. All kinds of complications were recorded. In a subgroup of 20 patients, the average loss of bone height of the condylar head joint surface was gauged by measuring the vertical distances from 3 selected reference points of the fixation hardware to the vertex of the condyle in views of multiplanar radiographs after 6 months. Functional outcome was analysed by Helkimo index score.

RESULTS

Complication rates were low. Osteosynthesis loosening occurred in 4 cases. The mean bone resorption along the condylar head joint surface in the subgroup of 20 patients (with 23 joints) was 0.7 mm. Functional outcome was rated as follows: 8 patients - good, 11 patients - slightly impaired, 1 patient - moderately impaired.

CONCLUSION

Open reduction and internal fixation of condylar head fractures with small-fragment screws leads to reliable results in terms of joint surfaces relatively resistant to resorption and function. Low bone resorption on the joint surface of the condylar head can be expected.

Relationship Between Intracapsular Fracture Patterns and Arthroscopic Findings

PURPOSE

To observe the superior joint compartment (SJC) using ultrathin arthroscopy in intracapsular condylar fracture (ICF) of the temporomandibular joint, describe the changes, and evaluate the relations among fracture pattern, arthroscopic findings, and clinical outcome.

PATIENTS AND METHODS

Twenty patients with 27 ICFs were the subject group. Thirteen patients had unilateral ICFs and 7 had bilateral ICF. The fracture patterns were classified into 9 categories, and all patients had arthroscopic examination of the traumatized joint at the time of definitive treatment. At 4 months after treatment of the injury, all patients had a secondary arthroscopy of the ICF joint. In all patients, range of motion (ROM) was measured as the interincisal distance (millimeters) at the first visit to 12 months after the first treatment, and the data were statistically evaluated.

RESULTS

Intra-articular hyperemia, hypervascularity, and temporal bone damage were found, and 4 patients had disc perforations at the first examination. At the second arthroscopy 4 months later, normal healing occurred in 11 joints, all of which had minimally displaced fractures. Fifteen joints showed complete filling of the SJC, all of which had a displaced minor fragment from the fossa. Comparison of the effect of the presence versus absence of SJC fibrosis on ROM showed marked differences from 1 to 12 months. The effect of early versus delayed definitive treatment showed marked differences at 4 and 12 months.

CONCLUSION

The intra-articular condition at 4 months after ICF as observed arthroscopically was related to the minor fragment position. If the minor fragment is nondisplaced, then it will heal to a normal state; however, if the minor fragment is displaced from the fossa, then the SJC shows disc damage and fibrosis. This could lead to fibrous ankylosis.

Long-term results of ORIF of condylar head fractures of the mandible: A prospective 5-year follow-up study of small-fragment positional-screw osteosynthesis (SFPSO)

BACKGROUND

Optimum treatment of condylar head fractures (CHF) remains subject to controversy. There are currently a variety of alternative techniques applied, data in literature are often inconsistent and especially systematic long-term data on results after treatment by open reduction and internal fixation (ORIF) have so far not been available. This study in hand is the first long-term prospective study of ORIF after CHF based on osteosynthesis with 1.7 mm small-fragment positional screws (SFPSO)via a retroauricular transmeatal approach (RA).

METHODS

The study made use of radiologic, anatomic and objective functional parameters (axiography and MRI) to assess vertical height, disk mobility, protrusive and translatory movement as well as potential physical complaints. Included were surgical long-term sequelae after RA, such as incidence of stenosis of the auditory canal, the facial nerve and resulting disturbance of facial skin sensitivity. Retroauricular scars were evaluated according to the Vancouver Scar Scale. Helkimo and RDC/TMD indices were applied for patient's self-assessment of quality of life aspects after ORIF via RA. The sample in the first follow-up trial (FFT) in the years 2003-2004 comprised 26 patients (36 CHF). 22 patients (31 CHF) were re-evaluated in a second follow-up trial (SFT) between 2006 and 2008. A reference collective (43 patients, 56 CHF) treated with ORIF from 1993 to 2000 mainly by mini- or microplates (MMP) served as a surgical control group.

RESULTS

Five years after ORIF all fractured condyles (FC) continued to show stable anatomic restoration of the pre-trauma vertical height. FC treated with SFPSO exhibited a significantly superior range of motion (p < 0.05) of disk and condyle during mouth opening and protrusion compared to a previous MMP reference collective. Also, no difference was found between condylar mobility of FC five years after surgery and non-fractured condyles (NFC). SFPSO had thus successfully achieved a sustainable, stable physiological restoration of protrusive mobility of the articular disk and condyle. Remarkably, these long-term results were even slightly better in SFT vs. FFT (p < 0.05). Except for sporadically occurring minor complaints, the patients' subjective overall long-term perception of the success of the treatment was equally positive to the surgeons' objective assessment.

CONCLUSIONS

This first long-term prospective follow-up study, based on objective assessment tools, demonstrates that in all cases the major goals of ORIF in CHF could be fully achieved. These goals are: restoration of vertical height viz. prevention of occlusal disorders, physiological function of disk and condyle as well as of the lateral pterygoid muscle. Accordingly, ORIF of CHF e.g. with SFPSO and via the RA secures both a long-term functionally and anatomically stable result and as best as possible pain-free result for the patient, a central prerequisite of optimum perceived HRQoL. The paper has been amended by an extensive review part that covers the current knowledge of the major surgical aspects regarding the treatment of condylar head fractures.