The retromandibular transparotid approach for reduction and rigid internal fixation using two locking miniplates in mandibular condylar neck fractures

Abstract

The condylar region is one of the most frequent sites of mandibular fracture. The management of these fractures has always been controversial. It is difficult to achieve optimal results especially in displaced condylar fractures with closed reduction as compared to open reduction and internal fixation (ORIF). ORIF provides better and quicker functional rehabilitation of the temporomandibular joint (TMJ). Various surgical techniques, approaches and fixation methods have been described for ORIF of condylar process fractures. Most surgeons prefer extraoral approaches over intraoral despite many associated complications as they provide good surgical exposure. The authors in their prospective single institution clinical study on 19 patients (13 patients had unilateral condylar neck fractures and six had bilateral condylar fractures, with condylar neck fractures on one side and subcondylar neck fractures on the other in three patients and condylar head fractures on the other in the remaining three patients) of condylar neck fracture have assessed clinical results in terms of the duration, efficacy, stability and safety of the surgical treatment of displaced condylar neck fractures by open reduction and rigid internal fixation using two 2.0-mm locking miniplates (AO; LOCK Mandible 2.0, MatrixMANDIBLE 2.0; Synthes, Paoli, PA, USA) via retromandibular transparotid approach. They have evaluated the morbidity/complications associated with the procedure at one week, one month and 3–6 months interval. The retromandibular transparotid approach with open reduction and rigid internal fixation for displaced condylar neck fractures of the mandible was found to be a feasible and safe, minimally invasive surgical technique that provides reliable clinical results. The technique described by the author is the standard Hind's variety of retromandibular approach which includes trans-parotid dissection to access the condylar region of the mandible. Two plate fixation technique was used. Only the condylar neck fractures were included in the study. One of the primary concerns for any surgeon is the accessibility to the condylar region for adequate reduction and fixation. The approaches described in the article were preauricular (for condylar head), retromandibular transparotid (for condylar neck) and transoral (for subcondylar fractures). All these approaches are time tested as far as the accessibility to the condylar region is concerned. The retromandibular transparotid approach is safe, expeditious and easy to perform. The present study is prospective single institution clinical study based on 19 patients who underwent ORIF using retromandibular transparotid approach for condylar neck fractures. The two plate fixation technique used by the surgeons is based on Meyer's principle of osteosynthesis. Using this principle compressive and tensile forces are neutralised in the condylar region. The time taken to perform the surgery was less than an hour. No complication was noticed in 6 months follow up. The present technique has not been compared with any other approach like antero-parotid transmasseteric approach. Some cases in the study were associated with midface and other mandibular fractures. It is unclear how the authors achieved centric occlusion without exposing the condylar neck fracture in question. The rationale for using locking plate in the condylar region is not mentioned in the discussion. Authors have classified three of their cases as “subcondylar neck fractures”, but this should be subcondylar fractures only as per literature. Method of MMF & reduction protocol is not there in the manuscript. The technique described by the author should be taught to aspiring Maxillofacial surgery trainees at teaching centres of the organization. The concept of transoral fixation of mandibular subcondylar fractures should be introduced in the service hospitals of our organization.