Mandibular Subcondylar Fractures: A Review on Treatment Strategies

Comparing Current Practice Habits for Treatment of Subcondylar Fracture Among Craniomaxillofacial Surgeons

Study Design

Survey.

Objective

Subcondylar fractures stand out as a particular challenge when treating maxillofacial trauma. The fracture site is often difficult to access and adjacent to critical structures like the facial nerve. Current treatment paradigms vary widely and we endeavored to elucidate these approaches from surgeons across the full breadth of Craniomaxillofacial Surgery.

Methods

A survey was designed to gather general background training and experience information, perceived indications for ORIF of subcondylar fractures, options for treating subcondylar fractures, and reasoning for choosing or not choosing a given treatment approach. The survey was sent to members of AO CMF and the American Academy of Facial Plastic Surgery. Responses were collected for 4 weeks.

Results

514 total responses to the survey were obtained (response rate 17%). Of these, 43 (8.4%) identified as Otolaryngology trained, 417 (81.1%) as OMFS trained, and 54 (10.5%) as Plastic Surgery trained. While there was broad agreement in the indications for open repair, surgical approaches differed by specialty background as well as AO faculty member status. Those with less experience were less likely to perform open approaches due to lack of comfort with this skill set.

Conclusions

There are some key differences in approaches to treatment of subcondylar fractures based upon specialty background and experience level. This provides an opportunity for further education to ensure optimal treatment for patients.

Facial Paresis After Mandibular Reconstruction

Condylar neck fractures are common injuries that occur in the facial and mandibular regions. The proximity of this area to the vital neurovasculature creates the increased importance of proper surgical intervention to limit damage to the underlying structures. Here, we report a case of a condylar neck fracture that resulted in temporary paresis of the facial nerve. In addition, a review of the literature regarding condylar fracture treatment and its complications was conducted.

Comparison of therapeutic results of closed and open repair of mandibular condylar fractures

BACKGROUND

Mandibular condylar fractures mostly result from traumatic accidents or strife. There is still dispute on the effectiveness of various therapeutic methods. Here we aimed to evaluate and compare the open or closed repair methods for mandibular condylar fractures.

METHODS

This is a clinical trial that was performed in 2015-2021 in Iran on all patients that referred to our medical centers with mandibular fractures due to traumatic events. Those cases with severe lateral dislocation of the mandibular condyles or severe dislocations of the fractured parts were assigned to the open surgical treatment group. The other patients were treated using Arch bar + intermaxillary fixation (IMF). The patient's abilities of mouth opening were assessed in centimeters within 1 month, 3 months, 6 months, 1 year and 2 years after the operations.

RESULTS

726 mandibular fractures were evaluated. Our data showed that 302 fractures (41.6%) were in the mandibular condyles. Of the 302 condylar fractures, 172 fractures (57.1%) occurred due to automobile accidents and 82 fractures (27.5%) occurred due to direct trauma. 203 patients (67.2%) underwent the close surgical procedures using maxillary and mandibular fixation using arch bar + IMF. 99 patients (32.8%) underwent open mandibular fixation operation and internal fixation (ORIF). Assessments of mouth opening showed significant improvements in this ability within the follow-up period in both groups (P<0.001 for both). Furthermore, we observed that patients treated by the open mandibular fixation procedure had significantly better results within the 6 months and 1 year after the procedures but after 2 years, no significant differences could be observed between groups.

CONCLUSION

Both open and closed surgical approaches for condylar fractures are associated with significant improvements, however, patients that were treated with ORIF had better clinical results in the first year after the surgical procedures.

Mandibular Subcondylar Fracture: Improved Functional Outcomes in Selected Patients with Open Treatment

BACKGROUND

Subcondylar fractures represent 25 to 35 percent of all mandibular fractures, yet the treatment paradigm has remained controversial. Closed treatment relies on the plasticity of the condyle head during recovery, whereas open treatment is challenging and risks facial nerve injury. Perioperative, functional, and patient-reported outcomes were measured to compare methods of open versus closed treatment of subcondylar fractures.

METHODS

Selected displaced subcondylar fracture cases with open (open reduction and internal fixation of subcondylar fracture with maxillomandibular fixation) versus closed (maxillomandibular fixation) treatment were compared (n = 60). Demographics, perioperative data, complications, persistent symptoms, chin deviation, malocclusion, change in mouth opening, functional scores, and FACE-Q patient satisfaction were recorded.

RESULTS

Open versus closed groups had similar demographics and perioperative data, except the open group had longer operating room time (76.39 minutes versus 56.15 minutes). In long-term follow-up, open-treated patients had fewer symptoms (9 percent versus 67 percent), less chin deviation (0 percent versus 40 percent), a less restricted mouth opening (3mm versus 5mm), and better functional scores (1.92 versus 0.861). Transient facial nerve weakness was seen in 6 percent of open cases.

CONCLUSION

For selected subcondylar fracture patients, open treatment with endoscopic assistance, nerve monitoring, and specialized plates provides superior long-term results compared to closed treatment when considering symptoms and functional parameters.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Prediction of Conservative Treatment Failure for Isolated Unilateral Mandibular Condylar Fractures Using Quantitative Measures: Suggestion of Indications for Intervention

BACKGROUND

Interest in the treatment of mandibular condyle fracture in cases of maxillofacial trauma has been a huge concern for decades because of a diversity of opinions on the topic and the relatively few studies conducted on individuals treated by physiotherapy or rehabilitation with or without intermaxillary fixation (IMF).

METHODS

We measured fracture gaps between bone ends over an 8-year period from 2012 to 2019. The study cohort was composed of only conservatively treated patients. This retrospective study was conducted to identify factors that influence treatment failure by comparing a functional treatment (physiotherapy) group with an IMF group in terms of fracture gaps and other variables. In addition, an algorithm was devised to enable clinicians to determine promptly whether IMF is needed for mandibular condylar fractures.

RESULTS

Significant correlations were observed between several parameters and malocclusion. Multiple regression analysis resulted in the following coefficients: 0.072 for fracture gap (P = 0.006) and 0.006 for age (P < 0.05) in functional treatment group. However, in the IMF group, correlations with malocclusion were 0.063 for fracture gap (P = 0.000) and 0.003 for age (P = 0.083).

CONCLUSIONS

We proposed a diagnostic algorithm for isolated unilateral mandibular condyle fractures that provides guidance regarding surgical correction. If indications for surgical correction, as regards anatomical location, fracture level, fracture gap between bone ends, and patient cooperability, are not satisfied, clinicians should select IMF or functional treatment (rehabilitation). If the fracture gap is less than 6 mm and the patient is cooperative, functional rehabilitation would be more suitable than IMF.

The Role of a Deep Neuromuscular Block in the Treatment of Mandibular Subcondylar Fractures

ABSTRACT

Mandibular fractures are the third most frequents maxillo-facial fractures. Most frequent site is the subcondylar region. Different approaches to reach subcondylar region, have been described. In the study was evaluated the advantages of neuromuscular block during endoscopic surgery for subcondylar fractures. Twenty-five patients affected by subcondylar fractures were enrolled in this study and divided in 2 groups; group A: patients who received an intraoperative booster of curare during surgical procedure and group B patients who underwent surgery treated without the intraoperative booster of curare. All patients were treated successfully by endoscope-assisted transoral approach. The analysis of time required for surgery showed a reduction in group A comparing to group B. The mean time for surgery for the patients in group B with displacement between 0° and 45° was 170 minutes, and for 45° to 90° was 230 minutes. In group A, the mean time was 117.5 minutes for patients with condylar displacement between 0° and 45°, and 147.5 minutes for the other group. In conclusion, deep neuromuscular block seems to improve the surgical conditions in patients undergoing subcondylar endoscopic assisted surgery, further study needs to assess this surgical technique in order to better define this surgical protocol.

Endoscopic surgery versus open reduction treatment of mandibular condyle fractures: A meta-analysis

The aim of the study was to compare open reduction with internal fixation (ORIF) and endoscopic open reduction with internal fixation (EORIF) of condylar fractures (CF) in adults in terms of reducing both needing of reoperation and/or facial nerve injury. An electronic search was undertaken (PubMed/MEDLINE, Web of Science, SCOPUS, and The Cochrane Library). The inclusion criteria were full text, published from their inception to June 2020, clinical trials, randomized or not, and retrospective studies, that compared ORIF and EORIF. The estimates of an intervention were expressed as the risk ratio (RR). From the 1338 articles found, 5 publications were included. There was no statistically significant difference between ORIF and EORIF regarding needing of reoperation (RR = 2.46, p = 0.42) or facial nerve injury (RR = 0.45, p = 0.14). Meta-analysis suggests that there is no difference between open reduction with internal fixation (ORIF) and endoscopic open reduction with internal fixation (EORIF) of condylar fractures (CF) regarding facial nerve injury risk or need for reoperation.

Clinical Assessment of Retromandibular Antero-Parotid Approach for Reduction of Mandibular Subcondylar Fractures: Report of 60 Cases and Review of the Literature

This study assessed the efficacy of the retromandibular antero-parotid approach for open reduction and internal fixation (ORIF) of subcondylar fractures. Sixty patients with the mean age of 31.03 years underwent surgical reduction with a 20–25mm incision in the retromandibular area with an antero-parotid transmasseteric approach. All patients were followed between 6 to 12 months. At the end of the first week, six patients exhibited postoperative malocclusion. At the next visits, all patients had optimal occlusion. Maximal interincisal opening (MIO) of 56 patients (93.3%) was >37mm, and only four patients (6.7%) had MIO<37mm. In three patients (5%), weakness of the buccal branch of the facial nerve was noticed postoperatively. No salivary gland complications were seen. The surgical scar was hardly noticeable. Retromandibular access with transmasseteric antero-parotid approach is the technique of choice for treatment of high- and low-level subcondylar fractures with adequate visibility and direct access to the condylar area.

Changes in mandibular and articular dynamics associated with surgical versus nonsurgical treatment of mandibular condylar fractures: a systematic review with meta-analysis

OBJECTIVE

The aim of this study was to evaluate the mandibular and articular dynamics and the presence of complications associated with surgical or nonsurgical treatments of condylar fractures.

STUDY DESIGN

Clinical trials that compared open reduction internal fixation and maxillomandibular fixation in patients with condylar fractures were included. We performed an electronic search of PubMed, Scopus, Cochrane Library, Web of Science, and LILACS (Latin American and Caribbean Health Sciences) databases starting from February 2017 and updated in January 2019 and found 467 articles. We evaluated methodologic quality by using the criteria from Cochrane's Collaboration Tool.

RESULTS

After independent screening of abstracts, we assessed the full texts of 88 articles; 9 studies were included for qualitative synthesis; but only 8 were included for the meta-analysis. Four studies were considered to have high risk of bias, and 5 were considered to have low risk. The risk ratio (RR = 0.20; 95% confidence interval [CI] 0.13-0.32) was observed for complications. The quality of evidence, using GRADE software, was considered low for maximum mouth opening and protrusive movement and moderate for lateral excursion movement and complications.

CONCLUSIONS

This review suggested that open reduction internal fixation and maxillomandibular fixation are effective. However, surgical treatment presented higher objective parameters. Nonsurgical treatment presented a high index of complications, such as malocclusion, pain and deviation.

Surgical Treatment for Extracapsular Condylar Fractures of the Mandible

BACKGROUND

Condylar fractures are considered the most controversial mandibular fractures, regarding both the diagnosis and the treatment. With the increase in surgical indications for handling this type of fracture, it is important to discuss about the advantages and disadvantages of the several surgical approaches available. This article describes the surgical details and postoperative results of the mini-retromandibular transparotid approach for treating extracapsular condylar fractures of the mandible.

METHODS

In a 1-year period, 16 patients affected by extracapsular condylar fractures with surgical indication were treated with the mini-retromandibular transparotid approach. All the surgeries were executed by the same surgeon. Preoperative and postoperative details of each patient were analyzed.

RESULTS

In the postoperatory, only 2 patients had purulent drainage in the associated fractures area and only 1 patient had paresis of the buccal branch of the facial nerve. No scar issues concerning the surgical wound were observed and reintervention was not necessary in any of the patients.

CONCLUSION

The mini-retromandibular transparotid approach offers advantages and should be included as an option for the open treatment of extracapsular condylar fractures of the mandible.

Surgical Management of Double/Triple Mandibular Fractures Involving the Condylar Segment: Our Perspective

A series of surgical cases operated in our unit are considered to analyze and evaluate the different techniques and sequencing employed in the surgical management of double/triple mandibular fractures involving a condylar fracture. Deviating from the normal sequence of reducing and fixing the dentate segment first, we addressed the condylar segment first. A combination of different approaches for different cases such as a periangular with a vestibular, a preauricular and a retromandibular with a vestibular were used according to the type of fractures. The accessibility to one difficult case with a medially displaced condyle was facilitated by using Hegar's uterine dilators. In all cases, good anatomical reduction was achieved with stable occlusion and without any signs of facial nerve impairment. The 'Condyle first' approach in the surgical management of double/triple mandibular fractures, is a reliable and efficient technique.

Retrospective Study of Facial Fractures

Aim:

The aim of this study was to give an insight into the retrospective analysis of a number of maxillofacial trauma cases reported to our institute and research center.

Materials and Methods:

The data for this study was obtained from the medical records and outpatient prescription slips of cases treated at the Oral and Maxillofacial Surgery Department from 2010 to 2016. Etiology, age, gender, pattern of fracture, and surgical treatment modalities undertaken in these patients were recorded.

Results:

A total of 353 maxillofacial trauma patients with mean age of 40 years, treated at our institute were evaluated from 2010 to 2016. Mandible was the most commonly fractured bone with parasymphysis as the most frequent site. Majority of victims were males (male:female ratio of 4:1) and also in the third decade of life. This study showed that 73% patients were treated by open reduction and internal fixation (ORIF), 25.8% by intermaxillary fixation (IMF) and Stabilization of fracture mandible with acrylic splint and circummandibular wiring was done in 0.8% pediatric patients.

Conclusion:

It was concluded that road traffic accidents were reported as the leading cause of maxillofacial fractures followed by assault, falls, and familial dispute. Maxillofacial surgeons as health care providers must continue their ‘face it’ campaign to decrease the incidence of road traffic accidents. Open reduction and internal fixation remains the gold standard treatment modality.

A New Method for Surgical Treatment of Subcondylar Fractures: A Case Report

Subcondylar fractures are common in the maxillofacial region following direct trauma to the mandibular ramus. The literature is replete with articles written on the treatment of subcondylar fractures, encompassing a plethora of various surgical approaches; however, the best treatment procedure has remained controversial. Such fractures are either treated by open reduction with internal fixation or closed reduction with maxillomandibular fixation. In this article, we describe a new surgical method for treatment of subcondylar fractures.