CRB modification to retromandibular approach for management of subcondylar fractures

The aim of this study was to evaluate the efficacy of CRB modification of retromandibular approach to gain surgical access for open reduction and internal fixation of mandibular sub-condylar fractures. A total number of 264 sustained extra-capsular subcondylar fractures from 230 patients were selected for the study over the period of 5 years. Evaluation of intraoperative accessibility, postoperative facial nerve function, postoperative complications and scar was ca-rried out. All the patients were treated using CRB Curvilinear approach. Patient follow up was re-corded for 1 year on a regular interval basis. Symptoms of postoperative facial nerve injury were seen in 2 patients which recovered with time, postoperative complications were not encountered in any case and minimum scar mark hidden in the cervical skin crease. Hence open reduction and internal fixation for Subcondylar fracture of mandible by using the CRB modification of re-tromandibular approach is a good alternative for other conventional approaches in having ease of access, ease of fixation, reduced incidences of injury to facial nerve and its branches with good aesthetic outcome

Outcomes of open versus closed treatment in the management of mandibular subcondylar fractures

OBJECTIVES: To compare the clinical and radiological outcomes after closed reduction (CR) and open reduction and internal fixation (ORIF) in the management of subcondylar fractures. MATERIALS AND METHODS: Forty-eight patients presenting with subcondylar fracture between January 2010 and March 2013 were evaluated retrospectively. Fifteen patients were treated with CR and 33 patients with ORIF. The clinical and radiologic parameters were evaluated during follow-up (mean, 7.06 months; range, 3 to 36 months). RESULTS: In the CR group, no patients had any problems with regard to the clinical parameters. The average period of maxillomandibular fixation (MMF) was 5.47 days. The preoperative average tangential angulation of the fractured fragment was 3.67degrees, and loss of ramus height was 2.44 mm. In the ORIF group, no clinical problems were observed, and the average period of MMF was 6.33 days. The preoperative average tangential angulation of the subcondylar fragment was 8.66degrees, and loss of ramus height was 3.61 mm. CONCLUSION: CR provided satisfactory clinical results, though ORIF provided more accurate reduction of the fractured fragment. So there is no distinct displacement of fractured fragment, CR should be selected than ORIF because of no need for surgery.

Transmasseteric Approach for Open Reduction and Internal Fixation of Mandible Subcondylar Fracture

PURPOSE: Surgical approaches to the condylar neck and subcondyle area can cause some morbidity such as, facial nerve injury, time-consuming nature and external scar etc. So many surgeons hesitate using open reduction and internal fixation for the treatment of subcondylar fractures. We report open reduction and internal fixation of subcondylar fractures in 13 adult patients via transmasseteric approach. METHODS: From 2007 to 2009, 13 adults with subcondylar fracture of mandible were treated with open reduction and internal fixation via transmasseteric approach. A preauricular incision was extended downwards in a curvilinear fashion in the cervicomastoid skin crease. Skin flap was elevated above the SMAS layer. Masseter muscle was splitted at the anteroinferior edge of the parotid gland. After the fracture was reduced, fixed with appropriate plates and screws. All operation were performed under general anesthesia. RESULTS: Mean follow-up period was 13.3 months. There were no signs and symptoms of facial nerve injury, difficulty in mouth opening, or malocclusion. Dissection time was roughly within 30 minutes. CONCLUSION: Transmasseteric open reduction and internal fixation of mandible subcondylar fracture can be performed with excellent visualization, and inconspicuous scar. It also offers swift access to the subcondylar area while substatially reducing the risk to the facial nerve and eliminating the complications associated with transparotid approaches.

Clinical Applications of Endoscopic-Assisted Open Reduction and Internal Fixation of Subcondylar Fractures

PURPOSE: The management of fractures of mandibular subcondyle continues to be controversial over open and closed treatment. The purpose of this article is to explain the endoscopic assisted open reduction and internal fixation and minimize the controversy. METHODS: For nine patients, mandibular subcondylar fracture were reduced and fixed by using intraoral endoscopic-assisted open reduction and internal fixation and were followed up for 14 - 24 months after the surgery. RESULTS: Eight patients of mandibular subcondylar fracture had been treated without significant complications. One patient, whose malocclusion had been remained, was recovered normal occlusion by maxillomandibular fixation using intermaxillary screws for 3 weeks. CONCLUSION: The advantages of endoscopic-assisted open reduction and internal fixation are direct visualization, accurate fracture repair, minimized scar, decreased morbidity. And maxillomandibular fixation is not needed when it is done by accurate reduction and rigid fixation with one miniplate in the region of subcondylar fracture. With the above consideration, endoscopic-assisted open reduction and internal fixation can be considered as one of the best treatments for subcondylar fracture of the mandible.

Case Report of Transparotid Approach of Mandibular Subcondylar Fracture

PURPOSE: Fractures of the mandibular condylar area are common injuries that account for 29% to 40% of fractures of the facial bones and represent 20% to 62% of all mandibular fractures. Currently 3 main methods are being used in the treatment of mandibular subcondylar fractures: closed reduction; open reduction and internal fixation; Endoscopic reduction and internal fixation. Each method has its proponents and opponent as well as advantages and disadvantages, and indications for each vary among surgeons. There are six approaches of open reduction: submandibular, retromandibular, preaurilcular, postauricular, intraoral, transparotid approach. Among them, transparotid approach has been described for subcondylar exposure with dissection in the direction of facial nerve fibers to expose the bone through the parotid gland. This approach carries the risk of a parotid glandular fistula as well as facial nerve injury but has the advantage of being directly over the fracture site. We report safety and efficacy of surgical treatment using a transparotid approach for direct plating. METHODS: A 43-year-old man sustained multiple facial bone fractures by driver traffic accident. Mandibular subcondyle was fractured and dislocated internally. We performed open reduction and internal fixation by transparotid approach. Fractured site was fixed by titanium mini plate & screw. We applicated arch bar for approximately 3 weeks. RESULTS: Follow-up length was about 5months. Scar of surgical incision was indistinct, there was no symptoms and signs of facial nerve and parotid gland injury, and maximal mouth opening was measured 49.5 mm. CONCLUSION: Transparotid approach has high risks of facial nerve and parotid gland injury, but paradoxically it is the most effective technique in saving facial nerve. Open reduction and internal fixation of mandibular subcondylar fracture by transparotid approach with precise and versed procedure, best outcome can be expected.

Comparison Study of Open Reduction and Closed Reduction in Treatment of Mandibular Subcondylar Fractures

PURPOSE: The choice of open versus closed reduction for mandibular subcondylar fracture is a debatable issue. To evaluate the advantage of open approach to closed method with IMF(intermaxillary fixation), we conducted a retrospective study to compare the outcomes of each method. METHODS: From 2002 to 2006, 29 patients with mandibular subcondylar fractures were treated by open or closed reduction. 17 patients were treated by open reduction and 12 patients by closed reduction and IMF. Each group was assessed for duration of mandibular immobilization, incidences of buccal palsy, malocclusion, TMJ(temporomandibular joint) pain, and deviation of the mandible on mouth opening. RESULTS: All cases showed accurate reduction in anatomical position, no significant displacement and no deviation on mouth opening during the follow-up period. IMF period is statistically shorter in open reduction (p<0.05). Differences in incidence of other complications were not significant statistically. CONCLUSION: As there are significant independent morbidities associated with IMF which requires postoperative rehabilitation, prolonged temporomandibular immobilization should not be overlooked. Some patients with poor compliances will not tolerate IMF in nonsurgical treatment. In the aspect of patient's convenience and early recovery by short IMF period, open reduction would be recommended as a better treatment method.

The literacture review and clinical evaluation of intraoral approach for subcondylar fracture

PURPOSE: The aim of this study was to investigate the clinical cases of subcondylar fracture with intraoral approach. MATERIAL AND METHOD: Fifteen patients with unilateral subcondylar fracture were treated in the department of oral and maxillofacial surgery, Kangdong Sacred Heart Hospital, College of Medicine, Hallym University between 2006 and 2007. Each patients was examined by computed tomography(CT) and panorama. 3D-CT taken when fractured segment was displaced and comminuted. Patients was done intermaxillary fixation to occlusal stability and prevent displacement of fractured segment before general operation. Open reduction and internal fixation(ORIF) accomplished under general anesthesia and used to intraoral approach. We examinated the state of occlusion, maximum opening. Evaluation of the state of occlusion was divided in patient's subjective evaluation that compare pre-traumatic occlusion with postoperative occlusion, and estimator's objective evaluation that use articulating paper. Examination was done at 2 weeks, 1, 3, 6 month postoperative by follow up. RESULT: The ORIF through intraoral approach was good in all patients. In the state of occlusion, all patients recovered pre-traumatic occlusion in 6 month postoperation. Maximum opening was gradually increased. In 3 month postoperative, maximum opening was excessed 40mm. CONCLUSION: Our study indicate that the intraoral approach is a good technique for subcondylar fracture. Intraoral approach prevent complication that facial nerve damage, scar formation caused by extraoral approach. So, we recommend intraoral approach when subcondylar fracture.

Post operative evaluation for retromandibular approach of subcondylar fractures

PURPOSE: The classic technique for open reduction of subcondylar fractures is the submandibular approach. The aim of this study was to evaluate clinical result of retromandibular approach to displaced subcondylar fractures. MATERIAL AND METHODS: During a period of 24months we perfomed a prospective study with a retromandibular approach in 23 paients with displaced subcondylar fractures. In this article we describe clinical result in 23 patients with follow ups for 3 months after surgery. Preoperatively all patients had malocclusion and radiology demonstrated displacement. RESULT: The retromandibularl approach for ORIF was good in all case. Mouth opening(M/O) was 49mm. Occlusion was good too. Permanent facial nerve palsy was not detected. CONCLUSION: Our findings indicate that the retromandibular approach is a safe technique for subcondylar fractures.

Endoscopic-assisted open reduction and internal fixation (EAORIF) for condylar fracture

The endoscopic assisted approach for the treatment of condylar fracture is a less invasive alternative treatment modality and is considered to be able to overcome the limited access to the operation field to obtain an accurate reduction and fixation. Six patients with condylar neck and subcondylar fracture underwent the endoscopic assisted open reduction and internal fixation through the transoral approach at the Department of Oral and Maxillofacial Surgery, Seoul National University Dental Hospital. The endoscope was inserted through an intraoral incision and the reduction of fracture fragment was performed via a transbuccal approach with two transcutaneous stab incisions. Five patients showed anatomic reduction without any complications. One patient, whose fracture site was fixed with a single plate, showed displacement of fractured condylar segment during the follow up period. No patient had any facial nerve damage.

Outcome of Open Reduction Via Retromandibular Approach for Mandibular Subcondyle Fracture

Subcondylar fractures have generally been treated by intermaxillary fixation except in cases where there is an absolute indication for open reduction. The reason behind a less aggressive surgical approach lies on the inherent difficulties in manipulating fragments in such a small area at the risk of damaging facial nerves or vessels such as the internal maxillary artery. However, long-term follow-up studies showed that conservative treatment of subcondylar fractures results in disturbances of occlusal function, deviation of the mandible, internal derangement of the temporomandibular joint, and ankylosis of the joint. We carried out open reduction of dislocated subcondylar fractures in 14 patients from 2000 to 2004 by a retromandibular approach. After the reduction of fractured bone, two H-shaped miniplates with 6 holes were fixed with screws at the anterior and posterior surfaces of the subcondyle. The retromandibular approach allowed good access and easy manipulation of the subcondyle. Immediate relief from malocclusion and correction of mandibular midline shifting were observed in all patients. Late temporomandibular dysfunction and ankylosis were not observed. Open reduction with plate osteosynthesis made it possible to avoid IMF in 7 of the 14 patients. The present study shows that open reduction through this retromandibular approach can produce good outcome in adult patients with subcondylar fracture.

The Endoscopic Repair of Mandibular Subcondylar Fracture through Intraoral Approach

The Endoscopic Repair of Mandibular Subcondylar Fracture through Intraoral Approach. The treatment of the mandibular subcondylar fractures has been controversal. But, recently open reduction and rigid internal fixation was advocated as a reliable method of anatomically restoring condylar position, early restoration of T-M joint function without intermaxillary fixation or with short intermaxillary fixation period. The endoscopic repair of mandibular subcondylar fractures not only provides better visualization in the surgical field, but also makes rigid fixation, avoids facial scarring and facial nerve injury. From March of 1996 to November of 2001, the endoscope was used successfully to assist in the repair of mandibular subcondylar fractures in twelve patients. An intraoral incision was made in the anterior aspect of the mandibular ramus, and a 5.0mm, 30-degree telescope was introduced by means of this intraoral incision to aid in the dissection and to visualize the fracture site over the subcondylar area. After subcondylar reduction by lateral force of the preauricular trocar and inferior traction of the mandibular angle, a 2mm miniplate was used to stabilize the fracture site with the help of a percutaneous trocar. The proper alignment of the posterior border of the ramus could also be checked under direct endoscopic vision. Intermaxillary fixation was maintained for 5 days postoperatively in the first four patients. All the patients were followed up for minimum of 2 months, and there were no facial palsy. The mean of maximal mouth opening was 44 mm within 6 weeks and the stab incision wound in the preauricular and angle area were inconspicuous. All patients obtained normal range of motion of temporomandibular joint. Although requirement of endoscopic equipments and surgical skills is necessary, the use of endoscope may reduce the disadvantages of open reduction and should be considered in the treatment of mandibular subcondylar fractures.

Technique for Open Reduction of Subcondylar Fractures Using Bended Iron Stick Scale

The methods of management for condylar fractures have been investigated and improved. The methods which have been used up to date are classified broadly into conservative and surgical treatment. Conservative treatment is chosen usually in the cases of children's or growing adolescent's fracture and non-displaced high leveled condylar fracture. But in the cases of displaced fracture, surgical reduction is to fit. The aim of surgical treatment is restore preexisting anatomical relationships by means of functionally stable rigid fixation. And rigid fixation will avoid uncomfortable IMF. Most miniplate fixations are accomplished through extraoral approaches. Extraoral approaches have the advantage of accurate reduction and fixation under a good visual field, but they have several disadvantages of facial nerve injury, facial scarring, and the possibility of necrotic bone change of fragment. Thus trocar assisted intraoral approach was introduced. But this method have disadvantage of uncertain fixation, because of visual field limitation and unaccurate reduction. To overcome this, we design a bended iron stick scale. The iron stick scale has 2 holes, 5 mm and 7 mm. apart from bending point for drilling. This hole was used for accuracy drilling. We treated 16 cases of displaced subcondylar fracture, using this method.

Treatment of subcondylar fracture of the mandible.

Forty eight patients with subcondylar fracture of the mandible were study prospectively. 42 patients were treated by non-reductive method and 6 patients were treated by open reduction and internal fixation method. The patients were followed up for about one to three years duration. AII of the patients treated by open reduction showed good alignment and good function. The patients treated by non-reductive method showed poorer alignment : nine cases could not protease normally. AII of the patients which could not profuse normally had been immobilized by intermaxillary fixation procedure. This study shows that non-reductive treatment without intermaxillary fixation can by used to treat the patients as a standard method.