Modified tragus edge incision and transmasseteric anteroparotid approach to condyle reconstruction / 华西口腔医学杂志

OBJECTIVES@#This study aimed to analyze the application value of a modified tragus edge incision and transmasseteric anteroparotid approach to condyle reconstruction.@*METHODS@#Condyle reconstruction was performed in 16 patients (9 females and 7 males) with modified tragus edge incision and transmasseteric anteroparotid approach. After regular follow-up, the function of condyle reconstruction was evaluated by clinical indicators, such as parotid salivary fistula, facial nerve function, mouth opening, occlusal relationship, and facial scar. The morphology of rib graft rib cartilage was evaluated by imaging indicators, such as panoramic radiography, CT, and three-dimensional CT image reconstruction.@*RESULTS@#At 6-36 months postoperative follow-up, all patients had good recovery of facial appearance, concealed incisional scar, no parotid salivary fistula, good mouth opening, and occlusion. One case had temporary facial paralysis and recovered after treatment. Radiographic evaluation further showed that costochondral graft survived in normal anatomic locations.@*CONCLUSIONS@#The modified tragus edge incision and transmasseteric anteroparotid approach can effectively reduce parotid salivary fistula and facial nerve injury in condylar reconstruction. The surgical field was clearly exposed, and the incision scar was concealed without increasing the incidence of other complications. Thus, this approach is worthy of clinical promotion.

Management of diacapitular mandibular condyle fracture using a single lag screw fixation: case report / Manejo de fractura de cóndilo mandibular diacapitular mediante fijación con tornillo de tracción único: reporte de caso

Introduction: Mandibular fractures are the most common facial fractures affecting various anatomical sites of the mandible. Among the various mandibular fractures, management of condylar fractures remains a challenging task for surgeons. Case Report: We report the case of a 28 year old male patient who presented with pain in the chin and restricted mouth opening. Computed tomography revealed a sagittal fracture of the right condylar head with medial displacement of the fractured fragments. Management of diacapitular fractures includes open reduction and internal fixation of the right condyle using a single lag-screw. Results: The postoperative outcomes were favorable, where normal mandibular movements, desired dental occlusion and exact positioning of the condyle with rigid fixation were established thereby maintaining the shape of the condyle. Conclusion: Use of single lag screw fixation is highly recommended as it greatly supports the stabilized fracture fragments and also aid in prevention of fracture fragment rotation medially.

Introducción: Las fracturas mandibulares son las fracturas faciales más comunes que afectan a diversos sitios anatómicos de la mandíbula. Entre las diversas fracturas mandibulares, el manejo de las fracturas condilares sigue siendo una tarea desafiante para los cirujanos. Reporte del Caso: Presentamos el caso de un paciente masculino de 28 años que consultó por dolor en el mentón y restricción de la apertura de la boca. La tomografía computarizada reveló una fractura sagital de la cabeza condilar derecha con desplazamiento medial de los fragmentos fracturados. El tratamiento de las fracturas diacapitulares incluye la reducción abierta y la fijación interna del cóndilo derecho con un solo tirafondo. Resultados: Los resultados postoperatorios fueron favorables, donde se establecieron los movimientos mandibulares normales, la oclusión dentaria deseada y el posicionamiento exacto del cóndilo con fijación rígida manteniendo así la forma del cóndilo. Conclusión: Se recomienda encarecidamente el uso de una fijación con un solo tornillo de tracción, ya que soporta en gran medida los fragmentos de fractura estabilizados y también ayuda a prevenir la rotación medial de los fragmentos de fractura.

Virtual surgical planning is a useful tool in the surgical management of mandibular condylar fractures / 中华创伤杂志(英文版)

PURPOSE@#The aim of this study is to evaluate the application value of virtual surgical planning in the management of mandibular condylar fractures and to provide a reliable reference.@*METHODS@#This was a prospective randomized controlled study and recruited 50 patients requiring surgical treatment for their mandibular condylar fractures. The inclusion criteria were patients (1) diagnosed with a condylar fracture by two clinically experienced doctors and required surgical treatment; (2) have given consent for the surgical treatment; and (3) had no contraindications to the surgery. Patients were excluded from this study if: (1) they were diagnosed with a non-dislocated or only slightly dislocated condylar fracture; (2) the comminuted condylar fracture was too severe to be treated with internal reduction and fixation; or (3) patients could not complete follow-up for 3 months. There were 33 male and 17 female patients with 33 unilateral condylar fractures and 17 bilateral condylar fractures included. The 50 patients were randomly (random number) divided into control group (25 patients with 35 sides of condylar fractures) and experimental group (25 patients with 32 sides of condylar fractures). Virtual surgical planning was used in the experimental group, but only clinical experience was used in the control group. The patients were followed up for 1, 3, 6 and 12 months after operation. Variables including the rate of perfect reduction by radiological analysis, the average distance of deviation between preoperative and postoperative CT measurements using Geomagic software and postoperative clinical examinations (e.g., mouth opening, occlusion) were investigated for outcome measurement. SPSS 19 was adopted for data analysis.@*RESULTS@#The average operation time was 180.60 min in the experimental group and 223.2 min in the control group. One week postoperatively, CT images showed that the anatomic reduction rate was 90.63% (29/32) in the experimental group and 68.57% (24/35) in the control group, revealing significant difference (X2 = 4.919, p = 0.027). Geomagic comparative analysis revealed that the average distance of deviation was also much smaller in the experimental group than that in the control group (0.639 mm vs. 0.995 mm; t = 3.824, p < 0.001).@*CONCLUSION@#These findings suggest that virtual surgical planning can assist surgeons in surgical procedures, reduce operative time, and improve the anatomic reduction rate & accuracy, and thus of value in the diagnosis and treatment of condylar fractures.

Mini suture anchor: An effective device for reduction and fixation of displaced temporomandibular joint disc with intracapsular condylar fracture / 中华创伤杂志(英文版)

PURPOSE@#The main aim is to provide clinical reference for the application of mini suture anchor in the reduction and fixation of displaced temporomandibular joint (TMJ) disc with intracapsular condylar fracture.@*METHODS@#From October 2018 to October 2019, 21 patients (31 sides) with intracapsular condylar fractures and articular disc displacement from West China Hospital of Stomatology, Sichuan University were included. The selection criteria were: (1) mandibular condylar fractures accompanied by displacement of the TMJ disc, confirmed by clinical examination, CT scan and other auxiliary examinations; (2) indication for surgical treatment; (3) no surgical contraindications; (4) no previous history of surgery in the operative area; (5) no facial nerve injury before the surgery; (6) informed consent to participate in the research program and (7) complete data. Patients without surgical treatment were excluded. The employed patients were followed up at 1, 3, 6 and 12 months after operation. Outcomes were assessed by success rate of operation, TMJ function and radiological examination results at 3 months after operation. Data were expressed as number and percent and analyzed using SPSS 19.0.@*RESULTS@#All the surgical procedures were completed successfully and all the articular discs were firmly attached to the condyles. The articular disc sufficiently covered the condylar head after the fixation. The fixation remained stable when the mandible was moved in each direction by the surgeons. No complications occurred. The functions of the TMJ were well-recovered postoperatively in most cases. CT scan revealed that the screws were completely embedded in the bone without loosening or displacement.@*CONCLUSION@#Mini suture anchor can provide satisfactory stabilization for the reduced articular disc and also promote the recovery of TMJ functions.

Condylar Dislocation for Intracranial Fossa: a Review of the Last 10 Years

The displacement of the mandibular condyle into the cranial fossa is an uncommon event; when it occurs, there is a need for immediate and multidisciplinary surgical intervention. Due to its rare advent, there is still no consolidated service dynamics, as this condition has not yet been described in a sedimented way in the literature databases. In the present article, we performed a literature review of condylar dislocation for the intracranial fossa described in the past 10 years in the PubMed and Lilacs search databases.

Abordaje intraoral con asistencia endoscópica para las fracturas de cóndilo mandibular: descripción de una serie de casos / Intraoral approach with endoscopic assistance for mandibular condyle fractures: a case series

Objetivo: Describir una serie de casos de fracturas de cóndilo mandibular resueltas por abordaje intraoral y asistencia video-endoscópica. Casos clínicos: Se presentan 3 casos de pacientes con fracturas de cóndilo mandibular unilateral. Dos casos presen- tan un segundo trazo de fractura parasinfisiaria asociada. El tratamiento realizado fue la reducción abierta y la fijación in- terna de todas las fracturas por abordaje oral. Se realizaron controles clínicos y tomográficos mediatos y a distancia (AU)

Aim: To present the experience with a series of cases re- solved by an intraoral approach and video-endoscopic assis- tance for the management of mandibular condyle fractures. Clinical cases: Three cases of patients with unilater- al mandibular condyle fractures are presented. Two of the cases presented a second line of associated parasymphyseal fracture. The treatment performed was open reduction and internal fixation of all fractures by oral approach. Mid-term and long-term clinical and tomographic follow-ups were per- formed, with favorable results (AU)

Tratamiento quirúrgico de fracturas de cóndilo mandibular: reducción asistida por endoscopio como complemento al tratamiento convencional / Surgical treatment of mandibular condyle fractures: endoscope-assisted reduction as a complement to conventional treatment

Resumen Introducción: Las fracturas de cóndilo presentan una alta incidencia dentro de las fracturas de mandíbula. Son principalmente tratadas por reducción abierta y fijación interna mediante elementos de osteosíntesis (ORIF) o por reducción cerrada (CR) con fijación máxilo-mandibular (MMF). El tratamiento asistido por endoscopio de estas fracturas, ofrece una alternativa y complemento quirúrgico a las limitaciones que se pueden presentar en la ORIF clásica. Objetivo: Describir la técnica de reducción quirúrgica asistida por endoscopio mediante acceso transoral y acceso retromandibular, como complemento a la técnica quirúrgica convencional para el tratamiento de fracturas de cóndilo mandibular, evaluando criterios clínicos en una serie de casos operados por esta técnica. Materiales y Método: Estudio descriptivo de presentación de serie de casos de pacientes con fractura de cóndilo, tratados con reducción quirúrgica asistida por endoscopio mediante accesos transoral y retromandibular, entre los años 2017 y 2018. Resultados: De los siete pacientes operados, un 85,7% presentó una función mandibular normal, un 100% presentó una función motora neurológica facial normal y un 71,4% no presentó dolor posoperatorio en el control de los 6 meses. Todos los pacientes recuperaron la oclusión que tenían de forma previa a la fractura mandibular. No se reportaron casos que tuvieran la necesidad de reintervención quirúrgica. Conclusiones: La reducción quirúrgica asistida por endoscopio para las fracturas de cóndilo mandibular es una técnica que ofrece un complemento a la técnica quirúrgica convencional, permitiendo mayor visibilidad de las estructuras, menor morbilidad quirúrgica y complicaciones mínimas en relación a las técnicas convencionales descritas.

Introduction: Condyle fractures have a high incidence within jaw fractures. They are mainly treated by open reduction and internal fixation with osteosynthesis elements (ORIF), or by closed reduction (CR) with maxillomandibular fixation (MMF). Endoscopic-assisted treatment of these fractures offers an alternative and surgical complement to the limitations that can occur in classic ORIF. Aim: To describe the technique of endoscope-assisted surgical reduction using transoral access and retromandibular access, as a complement to the conventional surgical technique for the treatment of mandibular condyle fractures, evaluating clinical criteria in a series of cases operated by this technique. Materials and Method: Descriptive study of case series presentation of patients with condyle fracture, treated with endoscopic assisted surgical reduction by transoral and retromandibular access, between the years 2017 and 2018. Results: Of the seven patients operated on, 85.7% presented normal jaw function, 100% presented normal facial neurological motor function, and 71.4% presented no postoperative pain at the 6-month control. All patients recovered the occlusion they had prior to the mandibular fracture. There were no reported cases in need of surgical reintervention. Conclusions: Endoscope-assisted surgical reduction for mandibular condyle fractures is a technique that offers a complement to the conventional surgical technique, allowing greater visibility of the structures, less surgical morbidity and minimal complications in relation to the conventional techniques described.

Functional recovery time after facial fractures: characteristics and associated factors in a sample of patients from southern Brazil / Tempo de recuperação funcional após fraturas faciais: perfil e fatores associados em amostra de pacientes do sul do Brasil

ABSTRACT Understanding the cause, severity, and elapsed time for the restoration of the functions of maxillofacial injuries can contribute to the establishment of clinical priorities aiming at effective treatment and further prevention of facial trauma. The objective of this study was to understand the factors associated with the restoration of mastication, ocular, and nasal functions in the face of trauma victims, estimating their recovery time after surgical treatment. We analyzed 114 medical records of patients treated at the Hospital Montenegro, who attended follow-up consultations for up to 180 days. For analysis of the recovery time, we performed survival analysis, followed by COX analysis. We observed that half of the patients recovered their functions within 20 days. The average time for recovery from trauma in the zygomatic-orbital-malar-nasal complex was 11 days, and in the maxillary-mandibular complex, 21 days (HR: 1.5 [0.99 2.3], p = 0.055). Although functional reestablishment has reached high rates after the surgical approach, it is necessary to analyze the failing cases, as well as the economic impacts and the prevention strategies associated with facial trauma, to improve the service to the population.

RESUMO O entendimento da causa, da gravidade e do tempo decorrido para o restabelecimento das funções de lesões maxilofaciais pode contribuir para o estabelecimento de prioridades clínicas objetivando o efetivo tratamento e prevenção dos traumatismos de face. Assim, o objetivo deste estudo foi compreender quais os fatores associados ao restabelecimento das funções mastigatórias, oculares e nasais em vítimas de trauma de face, estimando o tempo para recuperação das funções, após o tratamento cirúrgico. Foram analisados 114 prontuários de pacientes atendidos no Hospital de Montenegro que compareceram às consultas de acompanhamento por até 180 dias. Para a análise do tempo para a recuperação, foi realizada a análise de sobrevida, seguida da análise de COX. Observou-se que metade dos pacientes recuperaram as funções em até 20 dias, sendo que o tempo médio para recuperação dos traumas no complexo zigomático-orbitário-malar-nasal foi de 11 dias e do complexo maxilo - mandibular de 21 dias (HR: 1,5 (0,99 - 2,3) p=0,055). Embora o restabelecimento das funções tenha atingido taxas elevadas após abordagem cirúrgicas, faz-se necessária a análise dos casos de insucessos bem como os impactos econômicos e as estratégias de prevenção associados aos traumas de face a fim de qualificar o serviço prestado à população.

Fratura de mandíbula causada por projétil de arma de fogo: relato de caso / Mandible Fracture Caused by Firearm Projectile: Case Report

Introdução: A face é uma região exposta a diversos traumas que são causados por várias etiologias, dentre eles por projétil de arma de fogo que são a segunda maior causa de fraturas perdendo somente para os acidentes automobilísticos. As fraturas acometem com frequência a região mandibular, por ser um osso de destaque na face devido sua proeminência. O objetivo deste trabalho é elucidar uma fratura cominutiva na região de côndilo e colo mandibular causada por ferimento de arma de fogo e seu respectivo tratamento. Relato de Caso: Paciente de 25 anos, compareceu a um serviço de atendimento de cirurgia bucomaxilofacial vítima de um ferimento por arma de fogo. Após a realização dos exames de imagem constatou-se que o projétil estava alojado no pescoço da vítima, causando a fratura cominutiva o ramo e o côndilo mandibular do lado esquerdo. A paciente foi submetida a anestesia geral para realização da osteossíntese da fratura. Considerações finais: O diagnóstico e o tratamento são realizados por uma equipe multidisciplinar para que o tratamento seja o mais correto e efetivo, com finalidade de minimizar morbidades e mortalidades, já que os pacientes sobrevivem com sequelas permanentes quando o diagnóstico e o tratamento não são realizados de forma correta... (AU)

Introduction: The face is a region exposed to several traumas that are caused by several etiologies, among them a firearm projectile that is the second major cause of fractures losing only to automobile accidents. The fractures frequently affect the mandibular region, as it is a prominent bone in the face due to its prominence. The purpose of this study is to elucidate a comminuted fracture in the condyle and mandibular neck region caused by a firearm injury and its respective treatment. Case Report: A 25-year-old patient who attended a buccomaxillofacial surgery service as a victim of a gunshot wound. After imaging examinations it was found that the projectile was lodged in the victim's neck, causing the comminuted fracture of the branch and mandibular condyle on the left side. The patient underwent general anesthesia to perform the fracture osteosynthesis. Final considerations: Diagnosis and treatment are performed by a multidisciplinary team so that treatment is the most correct and effective, in order to minimize morbidities and mortalities, since patients survive with permanent sequelae when diagnosis and treatment are not performed correctly... (AU)

Stability as a key factor for bone repair in nonunion of mandibular osteotomy / Estabilidad como factor clave en la reparación de la nonunión de la osteotomía mandibular

Stability is necessary to ensuring proper bone repair after osteotomies and fractures. The aim of this research was to analyze how the repair of pseudoarthrosis sites was affected by different conditions in related to soft tissue. An experimental study was designed with 18 New Zealand rabbits. Six study groups were formed. An osteotomy was performed on the mandibular body of each animal and muscle was installed at the osteotomy site to model pseudoarthrosis. Fixation by surgery was then carried out, using plates and screws. The animals were submitted to euthanasia after 21, 42 and 63 days to make a descriptive comparison of the histological results. No animal was lost during the experiment. In all the samples, bone formation was observed with different degrees of progress. Defects treated with or without removal of the tissue involved in pseudoarthrosis presented comparable bone repair, showing that stability of the bone segments allows the repair of adjacent tissue. In some samples cartilaginous tissue was associated with greater bone formation. Stabilization of the fracture is the key in bone repair; repair occurs whether or not the pseudoarthrosis tissue is removed.

La estabilidad de las osteotomías y de las fracturas son fundamentales para asegurar la adecuada reparación ósea; el objetivo de esta investigación fue analizar la reparación presente en sitios de pseudoartrosis realizando la limpieza de la zona previo a la fijación o manteniendo el tejido de la nounión en el mismo lugar durante la osteosíntesis. Se diseñó un estudio experimental incluyendo 18 conejos de raza Neozelandesa. Se formaron 6 grupos de estudios a quienes se relizó una osteotomía en el cuerpo mandibular y posterior instalación de músculo en el lugar de la osteotomía para fabricar un modelo de pseudoartrosis. En cirugía posterior se fijó con placa y tornillos. Se realizaron eutanasias a los 42 y 63 días para comparar los resultados de forma descriptiva mediante estudio histológico. No fue perdido ningún animal durante el experimento. En todas las muestras evaluadas se observó formación ósea en diferentes niveles de avance; defectos tratados con o sin el retiro del tejido involucrado en la pseudoartrosis presentaron una condición de reparación ósea comparables, determinando que la estabilidad de los segmentos óseos permite la reparación del tejido adyacente. El tejido cartilaginoso se presentó en algunas muestras asociadas a sectores con mayor presencia de formación ósea. La estabilización de la fractura es clave en la reparación ósea; la reparación se produce manteniendo o retirando el tejido presente en la pseudoartrosis.

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

Tratamento fechado em fratura mandibular: parassinfisária e côndilar bilateral ­ relato de caso clínico / Closed treatment in mandibular fracture: bilateral parasymphyseal and condyle ­ clinical case report

Objetivo: relatar um caso de fratura na região parassinfisária e côndilar bilateral após acidente ciclístico, tratada pela técnica de bloqueio maxilomandibular. Relato de caso: paciente do gênero feminino, 21 anos, deu entrada no Hospital Municipal Waldemar das Dores, Barão de Cocais, MG, vítima de acidente ciclístico, apresentando fratura de esmalte e dentina nos dentes 11 e 21, mordida aberta anterior, com incapacidade de atingir a máxima intercuspidação, juntamente com uma limitação de excursão lateral para o lado direito. Após exames tomográficos, foi constatada fratura completa de colo de côndilo direito, fratura em galho verde em côndilo esquerdo e fratura de cortical lingual parassinfisária. Por se tratar de uma paciente jovem e por apenas uma de suas fraturas apresentar-se completa (colo do côndilo direito), foi proposto tratamento fechado, por meio do bloqueio maxilomandibular. Conclusão: o bloqueio maxilomandibular foi considerado um tratamento eficaz no caso em questão, no qual foi possível estabelecer a consolidação das fraturas sem ocorrência de complicações pós-tratamento.(AU)

Objective: to report a case of fracture in the bilateral parasymphyseal and condylar region after a cycling accident, treated with the maxillomandibular block technique. Case report: a 21-yearold female patient was admitted to the Waldemar das Dores Municipal Hospital, Barão de Cocais, MG, Brazil, victim of a cycling accident, showing enamel and dentin fracture in teeth 11 and 21, anterior open bite, inability to reach maximum intercuspation, and a lateral excursion limitation to the right side. Tomographic examinations showed complete fracture of the right condyle neck, greenstick fracture in the left condyle, and parasymphyseal lingual cortical fracture. Considering it is a young patient with only one complete fracture (neck of the right condyle), a closed treatment was proposed through maxillomandibular block. Conclusion: maxillomandibular block was considered an effective treatment for the case in question, allowing to establish fracture consolidation without post-treatment complications.(AU)

Consideraciones anestésicas en hipercapnia intraoperatoria, a propósito de un caso / Case report: Anesthetic considerations in intraoperative hipercapnia

Hypercapnia during the intraoperative period is one of the relevant conditions for the anesthesiologist, which can even condition the anesthetic technique, in case of an eventual complication. Where ventilatory monitoring and the interpretation of said disorder allows to diagnose, plan and treat the physiological consequences in the patient. We present the case of a 20 year old patient, scheduled for orthognathic surgery for diagnosis of mandibular body fracture, without added pathologies, no chest trauma, no ventilation disorders. It is presented with the objective of discussing the different considerations to be taken before the progressive establishment of hypercapnia, its causes, consequences and its management.

La hipercapnia durante el intraoperatorio es una de las condiciones relevantes para el anestesiólogo, la cual puede incluso condicionar la técnica anestésica ante una eventual complicación. Donde la monitorización ventilatoria y la interpretación de dicho trastorno permite diagnosticar, planificar y tratar las consecuencias fisiológicas en el paciente. Presentamos el caso de una paciente de 20 años programada para cirugía ortognática por diagnóstico de fractura de cuerpo mandibular, sin patologías añadidas no traumas torácicos, no trastornos de ventilación. Se presenta con el objetivo de discutir las diferentes consideraciones a tomar ante la instauración progresiva de hipercapnia sus causas, consecuencias así como su manejo.

Manejo cirúrgico de fratura de mandíbula: relato de caso / Surgical management of mandibular fracture: case report

Objetivo: descrever, por meio de um relato de caso, uma fratura de mandíbula em região de parassínfise esquerda, causada com agressão física. Relato de caso: paciente do sexo feminino, 26 anos de idade, ASA I, melanoderma, vítima de agressão física, procurou o serviço de Cirurgia e Traumatologia Bucomaxilofacial da Faculdade de Odontologia da Universidade Federal da Bahia. Ao exame físico, referiu queixas álgicas espontâneas em região mandibular esquerda e presença de degrau ósseo em região passinfisária esquerda. Ao exame de imagem, observaram-se sinais sugestivos de fratura em região de parassínfise esquerda. Na paciente em questão, foi realizado o manejo cirúrgico da fratura com auxílio de miniplacas e parafusos do sistema 2 mm em acesso intraoral. No acompanhamento pós-operatório, observaram-se material de osteossíntese e odontossíntese em posição, fratura adequadamente reduzida e ausência de sinais de deslocamento dos cotos fraturados. Considerações finais: o uso do sistema de fixação interna rígida é indicado em casos de fraturas desfavoráveis de mandíbula, uma vez que apresenta resultados satisfatórios referentes a estabilização e cicatrização óssea. A redução e a fixação com auxílio de miniplacas e parafusos tendem a evitar o deslocamento dos cotos fraturados e a formação de pseudoartrose. (AU)

Objective: to describe, through a case report, a mandible fracture in the left paraphysis region caused by physical aggression. Case report: female patient, 26 years old, ASA I, melanomedma, victim of physical aggression, researched at the Department of Oral and Maxillofacial Surgery and Traumatology from the Federal University of Bahia. In the physical exam, the patient referred spontaneos pain in the left parasymphysis and bone stepping in passinfisary left region. At the imaging examination observed suggestive signs of a fracture in the region of the left parasymphysis. The patient in question was approached by a surgical procedure of the fracture with miniplates and screws of the 2.0 mm system in an intraoral approach. Postoperatively, osteosynthesis and odontosynthesis material was observed in position, adequately reduced fracture and absence of signs of displacement of fractured stumps. Final considerations: the use of the internal fixation system is indicated in cases of unfavorable mandibular fractures once it presents satisfactory results regarding bone stabilization and healing. The reduction and fixation with miniplates and screws tend to avoid the displacement of fractured stumps and formation of pseudoarthrosis. (AU)

Fracturas Mandibulares Conminutadas por Impacto de Proyectil Balístico: Propuesta de Tratamiento Inicial Mediante Método de Fijación Alternativo / Mandibular Fractures Comminuted by Ballistic Projectile Impact: Initial Treatment Proposal Using Alternative Fixation Method

RESUMEN: El trauma maxilofacial por arma de fuego representa un desafío terapéutico principalmente debido a la gran conminución de tejidos que genera. Específicamente, en casos de fracturas mandibulares conminutadas, las modalidades de tratamientos incluye la reducción cerrada, fijación con tutor externo, fijación interna con alambres y reducción abierta y fijación interna utilizando placas y tornillos. El objetivo del presente trabajo es describir un tratamiento inicial con un método de fijación para fracturas mandibulares conminutadas como dispositivo alternativo al tutor externo clásicamente utilizado. Se desarrolla una revisión de la literatura actual acerca del tratamiento inicial o de urgencia de fracturas mandibulares conminutadas por impacto de proyectil balístico, haciendo énfasis en las indicaciones de cada modalidad de tratamiento y sus respectivas ventajas y desventajas. Luego se describe detalladamente el proceso de confección de un método de fijación alternativo junto con la exposición de casos clínicos donde fue utilizado como alternativa de tratamiento. La reducción y fijación obtenida por el dispositivo presentado logra resultados satisfactorios, sin encontrarse diferencias significativas a los elementos de fijación clásicos. Tanto el uso de placas de reconstrucción como el de tutor externo constituyen alternativas válidas para el tratamiento de fracturas mandibulares conminutadas. El dispositivo descrito y utilizado en los pacientes es una alternativa eficiente, de fácil confección y bajo costo económico demostrando buenos resultados en relación a la consolidación de fracturas conminutadas. Se debe conocer las indicaciones para la aplicación de cada modalidad de tratamiento.

ABSTRACT: Ballistic maxillofacial trauma represents a challenge for surgeons because of the important comminution process it presents. Specifically, in cases of mandibular comminuted fractures, the different treatment modalities include closed reduction, external fixation and internal fixation. The purpose of this case series is to describe an initial treatment modality, with a fixation method for comminuted mandibular fractures as an alternative for the classic external fixator. We conducted a literature review about the initial treatment for ballistic comminuted mandibular fractures, emphasizing indications of each treatment modality and their respective advantages and disadvantages. Next, we described the preparation process of an alternative fixation method along with a case series, where it was used as a therapeutical alternative. The reduction as well the fixation achieved by the external fixator, showed satisfactory results without significant differences noted with traditional fixation methods. Both, reconstruction plates and external fixators, are valid alternatives for treating comminuted mandibular fractures. The method described and used in these patients is and efficient alternative, easy to make and at a low cost, with good results in relation to fracture consolidation. We propose that every treatment modality and its indications should be evaluated in order to treat each case adequately.

Técnica de Boyne: una alterantiva en el tratamiento abierto de fracturas de cóndilo mandibular: a propósito de un caso clínico / Boyne´s technique: an alternative in the open treatment of mandibular condyle fractures: report of a clinical case

Las fracturas mandibulares son las fracturas más comunes de los huesos faciales; las de cóndilo mandibular ocupan un lugar importante entreellas. Dentro de sus factores etiológicos destacan los accidentes detránsito, agresión por terceras personas, accidentes deportivos y laborales. Existe gran controversia en el manejo de dicha entidad en cuantoa la elección de un tratamiento conservador o quirúrgico; hay varios factores considerados como razones para llevar a cabo el tratamiento quirúrgico, como la pérdida de altura facial posterior, la posición delcóndilo fracturado o la posibilidad de que el paciente adquiera el material de osteosíntesis. En este artículo presentamos una alternativa en el manejo quirúrgico de fracturas condilares mediante técnica de Boyne, así como una breve descripción de la técnica quirúrgica que empleamos en el Servicio de Cirugía Oral y Maxilofacial del Centro Médico Licenciado Adolfo López Mateos, la cual nos ha proporcionado adecuados resultados estéticos y funcionales.

Mandibular fractures are the most common fractures of the facial bones, with mandibular condylar fractures occupying an important place among them. Some of their etiological factors are traffic accidents, aggressions by third persons, sports, and work accidents.There is great controversy in the management of this entity, regardingthe selection of a conservative or surgical treatment; several factorsare considered reasons to carry out the surgical treatment, such as the loss of posterior facial height, the position of the fractured condylar, aswell as the possibility of having the patient purchase the osteosynthesis material. In this article, we present an alternative in the surgical management of condylar fractures using Boyne’s technique, as wellas a brief description of the surgical technique we used in the Oraland Maxillofacial Surgery Service of the Medical Center «Licenciado Adolfo Lopez Mateos¼, which has provided us with Suitable aestheticand functional results.

Caracterização miofuncional orofacial e eletromiográfica de pacientes submetidos à correção da fratura condilar por redução aberta e fechada / Oral-motor and electromyographic characterization of patients submitted to open and closed reductions of mandibular condyle fracture

RESUMO Objetivo Realizar a caracterização da performance motora orofacial de indivíduos adultos com fratura em côndilo, comparando indivíduos submetidos à redução aberta e fechada. Método 26 adultos divididos em três grupos: G1 – composto por 8 indivíduos submetidos à redução aberta para correção da fratura em côndilo; G2 – composto por 9 indivíduos submetidos à redução fechada para correção da fratura em côndilo; GC – 9 indivíduos voluntários saudáveis, sem alterações do sistema miofuncional orofacial. Todos os participantes foram submetidos à avaliação que consistiu na aplicação de um protocolo clínico para a avaliação da motricidade orofacial, a amplitude dos movimentos mandibulares e a avaliação da musculatura mastigatória por meio da eletromiografia de superfície (EMGs). Resultados Os resultados indicaram que ambos os grupos com fratura de côndilo se diferenciaram significantemente do grupo controle, apresentando prejuízo na mobilidade dos órgãos fonoarticulatórios e nas funções de mastigação e deglutição. Para as medidas de amplitude mandibular, os grupos se diferenciaram do grupo controle apresentando maior restrição de movimentos. Na avaliação dos músculos mastigatórios por meio da EMGs, G2 se diferenciou de G1 e de GC, apresentando maior assimetria no funcionamento do músculo masseter. Conclusão Os resultados sugerem que, independentemente do tratamento adotado para correção da fratura no período de até 6 meses após a correção, o desempenho motor oral e a amplitude dos movimentos mandibulares se mantêm iguais para os pacientes submetidos à redução aberta ou fechada das fraturas condilares. A redução aberta parece favorecer a simetria no funcionamento do músculo masseter.

ABSTRACT Purpose To characterize the oral-motor system of adults with mandibular condyle facture comparing the performance of individuals submitted to open reduction with internal fixation (ORIF) and closed reduction with mandibulomaxillary fixation (CRMMF). Methods Study participants were 26 adults divided into three groups: G1 – eight individuals submitted to ORIF for correction of condyle fracture; G2 – nine individuals submitted to CRMMF for correction of condyle fracture; CG – nine healthy volunteers with no alterations of the orofacial myofunctional system. All participants underwent the same clinical protocol: assessment of the orofacial myofunctional system; evaluation of the mandibular range of motion; and surface electromyography (sEMG) of the masticatory muscles. Results Results indicated that patients with condyle fractures from both groups presented significant differences compared with those from the control group in terms of mobility of the oral-motor organs, mastication, and deglutition. Regarding the measures obtained for mandibular movements, participants with facial fractures from both groups showed significant differences compared with those from the control group, indicating greater restrictions in mandibular motion. As for the analysis of sEMG results, G1 patients presented more symmetrical masseter activation during the task of maximal voluntary teeth clenching. Conclusion Patients with mandibular condyle fractures present significant deficits in posture, mobility, and function of the oral-motor system. The type of medical treatment does not influence the results of muscle function during the first six months after fracture reduction. Individuals submitted to ORIF of the condyle fracture present more symmetrical activation of the masseter muscle.

Distracción osteogénica en defecto mandibular complejo / Osteogenic distraction in complex mandibular defect

La distracción osteogénica (DO) es una técnica quirúrgica utilizada en el tratamiento de deformidades y malformaciones faciales, así como también en el tratamiento de deficiencias óseas de hueso alveolar. El objetivo de este artículo, es presentar el caso clínico de un paciente con edentulismo parcial del sector antero inferior, con una deficiencia ósea vertical y horizontal severa producto de un trauma mandibular.En el análisis inicial, el paciente relataba una historia reciente de fractura mandibular en sínfisis y ángulo derecho; el tratamiento con osteosíntesis no había sido totalmente exitoso, por lo cual, luego de estudiar lasopciones, se definió por un tratamiento en diferentes etapas: Etapa 1, cirugía para el retiro de osteosíntesis,preparación de tejidos blandos y reposición de margen posterior de sínfisis mandibular; etapa 2, distracción osteogénica, realizada luego de 3 meses de la primera intervención; y etapa 3, retiro del distractor e instalación de implantes, realizada 6 meses después de la segunda intervención. Se discuten algunos factores involucrados en el éxito del tratamiento.

Distraction osteogenesis (DO) is a surgical technique used in the treatment of facial deformities and malformations and also in the treatment of alveolar bone deficiencies. The aim of this paper is to show the case of a patient with partial edentulism in the symphysis area with a severe vertical and horizontal bone deficiency caused by mandibular trauma. At the initial analysis, the patient related a recent history of fracture in symphysis and right angle of the mandible. Treatment had not been entirely succesfull,therefore, after studying the options, we opted for a treatment at different stages: Stage 1, surgery for osteoshynthesis removal, soft tissue preparation and replacement of the posterior margin of mandibular symphysis;stage 2, distraction osteogenesis, performed 3 months after the first intervention and stage 3, distractor device removal and dental implant installation, performed 6 months after the second intervention. We discuss some factors involved in the treatment success.

Tratamiento de fracturas mandibulares / Treatment of mandibular fractures

Las fracturas y secuelas mandibulares son de difícil resolución en el ámbito de la cirugía maxilofacial, sus componentes hacen que su reducción no solo sea anatómica, sino también funcional. El objetivo de este artículo es realizar una revisión de los conocimientos más actuales en el tratamiento de fracturas y secuelas mandibulares y la presentación de un caso de secuela de trauma mandibular. El trata-miento de estas fracturas ha ido cambiando durante los últimos años, sirviéndose de nuevas tecnologías para lograr una mejor reducción a través de elementos de osteosíntesis, que propician abordajes más pequeños y con menor comorbilidad. Así el los nuevos sistemas de placas de titanio como miniplacas, placas de reconstrucción o autobloqueantes brindan excelentes resultados en traumas de alta energía con reducciones anatómicas más estables. La tecnología a través de sistemas de reconstrucción 3D y TAC intraoperatorios han logrado mejores resultados en la resolución de estos traumas.

Treatment of mandibular fractures and their sequelae are difficult to resolve in the maxillofacial surgery field, their components cause that reduction must not only be anatomic, but functional as well. The aim of this article is to present a review about actual knowledge in mandibular fracture treatmentand report a case of mandibular trauma. The treatment of these fractures has been changing through theyears; the new technologies achieve better reduction with the osteosynthesis systems, which results inreduced approaches and lesser morbidity. Presently, titanium plates systems like mini-plates, reconstruction plates or blocking plates offer excellent results in high energy traumas through anatomic and stable reductions. The technology of 3D reconstruction systems and intra-operatory CT accomplishes better results in trauma treatment.

Osteomielitis causante de fractura patológica: reporte de un caso / Pathological fracture resulting from osteomyelitis: report of a case

Las fracturas patológicas mandibulares son poco comunes, representanel 1 a 2% de todas las fracturas. Pueden ser defi nidas como fracturasque ocurren en regiones donde el hueso ha sido debilitado bajo un procesopatológico. Los factores de causa más comunes incluyen procesosquirúrgicos tales como extracciones de terceros molares, colocación deimplantes, osteonecrosis relacionada con bifosfonatos, osteorradionecrosisde la mandíbula, osteomielitis, infecciones, tumores o lesionesquísticas. La osteomielitis es una condición infl amatoria del hueso; estapatología es uno de los factores que puede determinar el debilitamientodel hueso mandibular y causar una subsecuente fractura patológica. Laosteomielitis mandibular se puede desarrollar si una infección primaria noes manejada adecuadamente. El tratamiento de las fracturas patológicaspuede representar un reto para el profesional de la salud y difi ere segúnla etiología de la misma. Se presenta un caso de una paciente de 54 añosde edad, con una fractura mandibular patológica causada por osteomielitis,la cual fue tratada con antibioticoterapia e intervención quirúrgica.

Pathological mandibular fractures are rare, accounting for between1 and 2% of all fractures. They can be defi ned as fractures thatoccur in regions where the bone has become weakened as a result of a pathological process. Common causal factors include surgicalprocedures such as third molar removal, implant placement, bisphosphonate-related osteonecrosis, osteoradionecrosis of the jaw,osteomyelitis, infections, tumors, and cystic lesions. Osteomyelitisis an infl ammatory condition of the bone; this pathology is one ofthe factors that may prompt weakening of the mandibular boneand cause subsequent pathological fracture. Osteomyelitis of themandible may develop if a primary infection is not properly treated.Treatment of pathological mandibular fractures can be challengingand varies according to their etiology. This article looks at the caseof a 54-year-old woman with a pathological mandibular fracture caused by osteomyelitis, which was treated by means of antibioticotherapy and surgical intervention.